Group List
Total quantity sold : 290 Date Billing First name Billing Last name Billing Company Billing E-mail Billing Phone Billing City Billing State Variation Order Qty Total _billing_diocese 2022-10-05 Katie Taylor Risen Savior Catholic Church [email protected] 605-231-0993 Brandon SD 14 Sioux Falls SD 2022-10-05 Magdalena Santiago Our Lady of Mercy/St. Mark the Evangelist [email protected] 814-899-3000 Erie PA 36 Erie 2022-10-05 Tammy Lamb SACRED HEART CATHOLIC CHURCH [email protected] 6417323428 Osage IA 10 Dubuque 2022-10-05 Hannah Berry St Paul Catholic Church [email protected] 6013834845 Flowood MS 40 Jackson 2022-10-05 Meridith Sledd Good Shepherd [email protected] 2568821844 Huntsville AL 25 Birmingham 2022-10-05 Jacqueline Ripberger St. John Bosco Youth Ministry [email protected] 8126394227 Jasper IN 15 Evansville 2022-10-05 Fr. Jay Suero St. Francis of Assisi [email protected] 7084600042 Orland Park IL 30 Chicago 2022-10-04 Karen Janssen St Thomas [email protected] 2172425283 Golden IL 30 Springfield 2022-10-04 Craig Gehlhausen St. Isidore [email protected] 812-634-1875 Celestine IN 15 Evansville 2022-10-04 Kyle Naugle Catalyst Catholic [email protected] 8129238355 Mt. St. Francis IN 35 Indianapolis 2022-10-03 Mary Frances Strange St. James Catholic Church [email protected] 6628424881 Tupelo MS 40 Jackson, MS Email selected customers
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| Participant Name | Nickname | Parish / Group | Have you attended CHWC before? | How many years? | Gender | Shirt Size | Age Category (at the time of camp) | Grade entering in the fall of 2023 | Cell Phone | First Choice Service Assignment | Second Choice Service Assignment | Construction: | 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 Camp | Participant Date of Birth | Emergency Contact | Emergency Contact, Relationship to Participant | Emergency Contact, Phone Number | Health Status: Please list any health problems you may have | Please list all medications taken routinely (over the counter and prescription) | Physician Name | Physician Phone Number | Date of your last Tetanus Booster | Health Insurance: Provider | Health Insurance: Policy Number | Health Insurance: Group Number | RELEASE OF ALL CLAIMS | MEDIA WAIVER | CODE OF BEHAVIOR | Participant Signature | Custodial Parent Name | Custodial Parent Signature | Custodial Parent Email | SIGNATURE AGREEMENT | Are you a member of clergy or professed religious? | Please Specify | Entry ID | Sequence Number | Entry Date | Delete 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 | January 26, 2023 10:17 AM | |||||||||||
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 | January 25, 2023 4:46 PM | ||||||||||
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 | January 25, 2023 11:36 AM | |||||||||||||
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 | January 24, 2023 11:45 AM | ||||||||||
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 | January 21, 2023 3:05 PM | |||||||||||
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 | January 21, 2023 1:59 PM | |||||||||
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 | January 20, 2023 3:55 PM | ||||||||||
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 | January 20, 2023 9:13 AM | ||||||||||||||
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 | January 20, 2023 9:03 AM | ||||||||||
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 | January 19, 2023 10:02 PM | ||||||||||||
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 | January 19, 2023 7:42 PM | ||||||||||||
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 | January 19, 2023 7:30 PM | ||||||||||||
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 | January 19, 2023 7:24 PM | ||||||||||||
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 | January 19, 2023 7:20 PM |