Group List

Date Billing First name Billing Last name Billing Company Billing E-mail Billing Phone Billing City Billing State Variation Order Qty Total _billing_diocese
2022-10-05KatieTaylorRisen Savior Catholic Church[email protected]605-231-0993BrandonSD14Sioux Falls SD
2022-10-05MagdalenaSantiagoOur Lady of Mercy/St. Mark the Evangelist[email protected]814-899-3000EriePA36Erie
2022-10-05TammyLambSACRED HEART CATHOLIC CHURCH[email protected]6417323428OsageIA10Dubuque
2022-10-05HannahBerrySt Paul Catholic Church[email protected]6013834845FlowoodMS40Jackson
2022-10-05MeridithSleddGood Shepherd[email protected]2568821844HuntsvilleAL25Birmingham
2022-10-05JacquelineRipbergerSt. John Bosco Youth Ministry[email protected]8126394227JasperIN15Evansville
2022-10-05Fr. JaySueroSt. Francis of Assisi[email protected]7084600042Orland ParkIL30Chicago
2022-10-04KarenJanssenSt Thomas[email protected]2172425283GoldenIL30Springfield
2022-10-04CraigGehlhausenSt. Isidore[email protected]812-634-1875CelestineIN15Evansville
2022-10-04KyleNaugleCatalyst Catholic[email protected]8129238355Mt. St. FrancisIN35Indianapolis
2022-10-03Mary FrancesStrangeSt. James Catholic Church[email protected]6628424881TupeloMS40Jackson, MS

Total quantity sold : 290

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Camper Paperwork (AKA Applications)

Participant NameNicknameParish / GroupHave you attended CHWC before?How many years?GenderShirt SizeAge Category (at the time of camp)Grade entering in the fall of 2023Cell PhoneEmailFirst Choice Service AssignmentSecond Choice Service AssignmentConstruction:Concrete/Masonry:Drywall:Painting:Plumbing:Electrical:Any comments to help place you on a team?Are there any health issues we need to know about before placing you at a worksite?Other Jobs at CampParticipant Date of BirthEmergency ContactEmergency Contact, Relationship to ParticipantEmergency Contact, Phone NumberHealth Status: Please list any health problems you may havePlease list all medications taken routinely (over the counter and prescription)Physician NamePhysician Phone NumberDate of your last Tetanus BoosterHealth Insurance: ProviderHealth Insurance: Policy NumberHealth Insurance: Group NumberRELEASE OF ALL CLAIMSMEDIA WAIVERCODE OF BEHAVIORParticipant SignatureCustodial Parent NameCustodial Parent SignatureCustodial Parent EmailSIGNATURE AGREEMENTAre you a member of clergy or professed religious?Please SpecifyEntry IDSequence NumberEntry DateDelete Entry Link
Alexandra Shaffer
Alex
Catalyst Catholic
No
Female
Small
Youth (under 18)
9th
Work with children at day care centers for low-income families
Work at a social service center (homeless shelter, food distribution center)
2
1
1
2
1
1
05/19/2009
Tiffany Shaffer
mother
(404) 509-2294
NA
doxycycline 50mg PO QD
multivitamin PO QD
Dr Jill Howell-Berg
(812) 280-6623
06/30/2020
Humana
003055735
923382
AGREE
AGREE
AGREE
Tiffany Shaffer
AGREE
318
1
David Halter
Dave
Risen Savior Catholic Church
Yes
8
Male
XL
Adult (21 and older)
(605) 212-5169
Work project (painting, indoor clean up, maintenance, repair work, outdoor yard work)
Work at a social service center (homeless shelter, food distribution center)
5
5
5
5
5
5
05/14/1967
Kathy Halter
Wife
(605) 929-6862
Seasonal allergies.
Zyrtec
Dr Nathan Briggs
(605) 582-3853
05/10/2018
Blue Cross Blue Shield
DKDW00516112
86764
AGREE
AGREE
AGREE
AGREE
No
308
2
Ella Vincent
Catalyst Catholic
No
Female
Medium
Youth (under 18)
11th
Work project (painting, indoor clean up, maintenance, repair work, outdoor yard work)
Work at a social service center (homeless shelter, food distribution center)
1
1
1
3
1
1
Please place on team with Breah Fitzgerald
04/03/2007
Jennifer Vincent
Mom
(608) 345-6312
Dr. McMonigle
(812) 949-0405
07/05/2018
UMR United Healthcare
22496728
76-010639
AGREE
AGREE
AGREE
Jennifer Vincent
AGREE
296
3
Katherine Taylor
Katie
Risen Savior Catholic Church
No
Female
Medium
Adult (21 and older)
(507) 301-1330
Work with children at day care centers for low-income families
Work project (painting, indoor clean up, maintenance, repair work, outdoor yard work)
3
2
3
5
4
1
Sensitive to heat, have a height issue.
Troubleshooter: Assist multiple work teams during the week
08/01/1989
Ali Gall
Sister
(402) 980-6687
allergy to avocado, cats, dairy
Dr. Wendy Vetter
(605) 328-9100
04/17/2017
United Healthcare Company
23643771
76414717
AGREE
AGREE
AGREE
AGREE
No
288
4
Solomon Ernstberger
Catalyst Catholic
No
Male
Medium
Youth (under 18)
9th
Work project (painting, indoor clean up, maintenance, repair work, outdoor yard work)
Work with children at day care centers for low-income families
2
1
1
2
1
1
No
01/15/2009
Elizabeth Ernstberger
Mother
(502) 807-6844
None
None
Dr. Tresa Ratterman
(812) 280-6623
07/31/2020
United Healthcare
06239727905
1431254
AGREE
AGREE
AGREE
Elizabeth Ernstberger
AGREE
250
5
Augustus Ernstberger
Gus
Catalyst Catholic
Yes
2
Male
Large
Youth (under 18)
11th
Work at a social service center (homeless shelter, food distribution center)
Work project (painting, indoor clean up, maintenance, repair work, outdoor yard work)
2
1
1
4
2
1
No
02/02/2023
Elizabeth Ernstberger
Mother
(502) 807-6844
None
None
Dr. Tresa Ratterman
(812) 280-6623
03/14/2018
United Healthcare
06239727902
1431254
AGREE
AGREE
AGREE
Elizabeth Ernstberger
AGREE
249
6
John Jacobi
Catalyst Catholic
Yes
2
Male
2XL
Adult (21 and older)
(812) 946-0873
Work at a social service center (homeless shelter, food distribution center)
Work project (painting, indoor clean up, maintenance, repair work, outdoor yard work)
2
1
1
5
1
1
01/18/1970
Carmen Jacobi
Wife
(812) 364-4670
N/A
Vitamins
Dr. John Reinoehl
(812) 738-4155
06/02/2008
UMR
18921672
76-413043
AGREE
AGREE
AGREE
AGREE
Yes
Deacon
241
7
Connor Zwissler
Catalyst Catholic
No
Male
Large
Youth (under 18)
10th
Work project (painting, indoor clean up, maintenance, repair work, outdoor yard work)
Work at a social service center (homeless shelter, food distribution center)
2
1
1
2
1
1
08/24/2007
James Zwissler
Father
(812) 725-3822
Dr Phillip Johnson
(812) 923-2273
01/15/2021
Caresource
111170265-00
54192IN001001104
AGREE
AGREE
AGREE
James Zwissler
AGREE
233
8
Allie Zwissler
Catalyst Catholic
No
Female
Small
Youth (under 18)
9th
Work with children at day care centers for low-income families
Work at a social service center (homeless shelter, food distribution center)
1
1
1
2
1
1
Great working with people and children
no
04/17/2009
James Zwissler
father
(812) 725-3822
allergies
Xyzal, Zyrtec, Flonase
Dr Phillip Johnson
(812) 923-2273
01/15/2021
Care Source
111170265
54192IN001001104
AGREE
AGREE
AGREE
James Zwissler
AGREE
231
9
Kate Wise
Katie
Catalyst Catholic
Yes
1
Female
Small
Young Adult (18-20)
(812) 572-1680
Work project (painting, indoor clean up, maintenance, repair work, outdoor yard work)
Work at a social service center (homeless shelter, food distribution center)
1
1
1
3
2
1
05/21/2005
Donna Wise
Mother
(812) 972-1736
Zyrtec 10 mg daily for allergies
multivitamin daily
Calcium gummy daily
Tylenol and Advil as needed for pain
Dr Janet Streepy
(812) 364-4669
07/13/2016
Anthem Blue Cross Blue Shield
WBTAN8807716
W33023M035
AGREE
AGREE
AGREE
AGREE
228
10
Sydney Kaelin
Catalyst Catholic
Yes
2
Female
Small
Youth (under 18)
11th
Work at a social service center (homeless shelter, food distribution center)
Work with children at day care centers for low-income families
1
1
1
2
1
1
06/11/2007
Keisha Kaelin
Mother
(812) 844-6999
Zyrtec
Cynthia Nassim
(812) 949-0405
07/10/2018
Anthem
YZD584M56059
W11710M001
AGREE
AGREE
AGREE
Keisha Kaelin
AGREE
221
11
Jace Martin
Catalyst Catholic
Yes
2
Male
Medium
Youth (under 18)
11th
Work project (painting, indoor clean up, maintenance, repair work, outdoor yard work)
Work at a social service center (homeless shelter, food distribution center)
2
1
1
2
1
1
Sunburns easily
01/05/2007
Angela/Chris Martin
Mother/Father
(812) 267-3282
Dr. Bickers
(812) 923-2273
01/06/2017
Anthem
AJS232M54048
L01467M018
AGREE
AGREE
AGREE
Angela Martin
AGREE
219
12
Xavier Jansen
Catalyst Catholic
No
Male
Medium
Youth (under 18)
10th
Work project (painting, indoor clean up, maintenance, repair work, outdoor yard work)
Work at a social service center (homeless shelter, food distribution center)
4
2
1
3
2
2
04/01/2008
Tracy Jansen
Mother
(502) 558-2585
Seasonal allergies, ADHD
Jornay, taken in the evening (May or may not take it during the mission trip)
Dr. Lane
(812) 944-4575
01/06/2012
United
856509094
730263
AGREE
AGREE
AGREE
Tracy Jansen
AGREE
218
13
Evan Wise
Catalyst Catholic
Yes
1
Male
XL
Adult (21 and older)
(812) 207-3482
Work project (painting, indoor clean up, maintenance, repair work, outdoor yard work)
Work with children at day care centers for low-income families
5
4
3
5
1
1
I've worked building decks and theatrical set peices
No
Associate Staff: Stay at home base and work behind the scenes with the HEART staff. ,Troubleshooter: Assist multiple work teams during the week
06/25/2023
Tammy Wise
Mother
(812) 989-2319
None
None
None
(000) 000-0000
10/19/2017
Anthem
Vsv497w05748
In2002m002
AGREE
AGREE
AGREE
AGREE
No
215
14