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
2022-10-24KatherineAguilarSt. Leo the Great Catholic Church[email protected]7035916089FairfaxVA20Arlington
2022-10-05KennedyRecordSt. Matthew Catholic Church[email protected]2176213355ChampaignIL20Diocese of Peoria
2022-10-05GrantBrightSt. Mary of the Annunciation[email protected]8472230010MundeleinIL13Chicago
2022-10-05MattBelfordSt. Joseph[email protected]612-548-4659HastingsMN18St. Paul/Minneapolis
2022-10-05TerriRiesselmannDivine Savior Parish[email protected]2629455778FredoniaWI20Milwaukee

Total quantity sold : 91

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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
Jackson Mayer
Jack
Divine Savior Parish
No
Male
Medium
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
11/10/2008
Lori Mayer
Mother
(414) 750-4970
none
none
Dr. Jeffrey Goza
(262) 334-3451
09/23/2020
BCBS Minnesota
RBP125157960001
10527076
AGREE
AGREE
AGREE
Lori Mayer
AGREE
358
1
Beau Peiffer
Beau
Divine Savior Parish
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)
2
2
1
2
2
1
No
09/20/2007
Michelle Peiffer
Mothet
(262) 617-2530
Dr. Staehling
(920) 476-6300
08/15/2022
exceedent
688288366
Fh0050
AGREE
AGREE
AGREE
Michelle Peiffer
AGREE
349
2
Amanda Hummel
St. Matthew Catholic Church
No
Female
Small
Young Adult (18-20)
(217) 390-7975
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
3
1
1
10/24/2004
Kristin Hummel
Mother
(217) 898-4695
back trouble
ibuprofen,
Francis Lee
(217) 366-6104
07/15/2020
BlueCross/BlueShield
TEA806239096
P13168
AGREE
AGREE
AGREE
AGREE
No
316
3
Gianna Kreps
St. Matthew Catholic Church
Yes
1
Female
Medium
Young Adult (18-20)
(217) 418-1803
Work project (painting, indoor clean up, maintenance, repair work, outdoor yard work)
Work at a social service center (homeless shelter, food distribution center)
3
1
2
4
1
1
05/21/2005
Britta Kreps
Mother
(217) 390-4509
Allergic to the penicillins, I had shoulder surgery a year and a half ago.
Allergy medication (pseudoephedrine), ibuprofen
Stefanie A. Schroeder
(217) 365-6200
07/15/2022
Meridian
177781952
361728796
AGREE
AGREE
AGREE
AGREE
No
315
4
Ethan Keller
Divine Savior Parish
No
Male
Large
Youth (under 18)
11th
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
Ethan works on a farm and helps with yard work and landscaping in addition to taking care of and feeding the animals.
Allergic to poison ivy, poison oak and poison sumac. I will send along a steroid cream just in case.
09/26/2006
Jodi Keller
Mother
(262) 689-4253
none
Triamcinolone Acetonide Cream as needed for poison ivy, oak or sumac. Apply 3 times daily to affected area.
Dr. Steven Pizer
(920) 457-4461
08/27/2017
Anthem
WZL0047821BM
JWI054M020
AGREE
AGREE
AGREE
Jodi Keller
AGREE
294
5
Cole Keller
Divine Savior Parish
Yes
1
Male
Large
Youth (under 18)
11th
Work project (painting, indoor clean up, maintenance, repair work, outdoor yard work)
Work with children at day care centers for low-income families
1
1
1
2
1
1
I work on a farm and do yard work and landscaping things besides feeding animals and chores.
No
09/26/2006
Jodi Keller
Mother
(262) 689-4253
None
None
Dr. Steven Pizer
(920) 459-1480
10/06/2017
Anthem
WZL0047821BM
JWI054M020
AGREE
AGREE
AGREE
Jodi Keller
AGREE
293
6
Joshua Kreps
Josh
St. Matthew Catholic Church
No
Male
XL
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
2
1
08/13/2008
Britta Kreps
Mom
(217) 390-4509
allergic to tomatoes
Dr. Sean Fullan
(217) 365-6200
01/22/2023
Meridian
196823975
361728796
AGREE
AGREE
AGREE
Britta Kreps
AGREE
253
7
Katherine Dimmer
Kati
Divine Savior Parish
No
Female
Medium
Adult (21 and older)
(920) 980-7215
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
3
3
1
1
07/21/1986
Cory Dimmer
Husband
(920) 946-1826
Dena M. Horvath
(920) 449-7220
05/28/2014
United Health Care
990079877
712332
AGREE
AGREE
AGREE
AGREE
No
239
8
Terri Riesselmann
Divine Savior Parish
Yes
Female
Medium
Adult (21 and older)
(262) 692-9994
Work at a social service center (homeless shelter, food distribution center)
Work with children at day care centers for low-income families
2
1
1
4
1
1
Associate Staff: Stay at home base and work behind the scenes with the HEART staff. 
03/24/1969
Eric Riesselmann
Husband
(262) 945-5969
Dr. Anna Kleyman
(262) 268-5100
10/26/2021
UMR-United Healthcare
19523698
76-040188
AGREE
AGREE
AGREE
AGREE
No
187
9