Group List
Total quantity sold : 91 Date Billing First name Billing Last name Billing Company Billing E-mail Billing Phone Billing City Billing State Variation Order Qty Total _billing_diocese 2022-10-24 Katherine Aguilar St. Leo the Great Catholic Church [email protected] 7035916089 Fairfax VA 20 Arlington 2022-10-05 Kennedy Record St. Matthew Catholic Church [email protected] 2176213355 Champaign IL 20 Diocese of Peoria 2022-10-05 Grant Bright St. Mary of the Annunciation [email protected] 8472230010 Mundelein IL 13 Chicago 2022-10-05 Matt Belford St. Joseph [email protected] 612-548-4659 Hastings MN 18 St. Paul/Minneapolis 2022-10-05 Terri Riesselmann Divine Savior Parish [email protected] 2629455778 Fredonia WI 20 Milwaukee 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 | |
|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|
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 | January 28, 2023 11:20 AM | |||||||||||
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 | January 27, 2023 12:12 PM | ||||||||||||
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 | January 25, 2023 9:41 PM | ||||||||||||
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 | January 25, 2023 9:38 PM | |||||||||||
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 | January 24, 2023 11:26 PM | ||||||||||
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 | January 24, 2023 11:23 PM | |||||||||
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 | January 22, 2023 5:49 PM | ||||||||||||
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 | January 20, 2023 1:40 PM | |||||||||||||
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 | January 19, 2023 3:19 PM |