Group List
Total quantity sold : 232 Date Billing First name Billing Last name Billing Company Billing E-mail Billing Phone Billing City Billing State Variation Order Qty Total _billing_diocese 2023-01-18 Maddie Pikus Calvert Hall College High School [email protected] 9087211400 Baltimore MD 10 Baltimore 2022-10-19 Allison Furnald St. Lawrence The Martyr Church [email protected] 4848944155 Chester NJ 24 Paterson 2022-10-05 Janice Dagney Our Lady of Consolation Early Learning Center [email protected] 484-995-4715 Parkesburg PA 16 Philadelphia 2022-10-05 Melissa Boyle St. Jane France [email protected] 4102554646 pasadena MD 16 Baltimroe 2022-10-05 Stephanie Tierney St. Fabian [email protected] 248.921.0442 Farmington Hills MI 35 Archdiocese of Detroit 2022-10-05 Becky Phillips Holy Mother of Consolation [email protected] 608-835-5764 Oregon WI 35 Madison 2022-10-05 Sarah Elmer Holy Spirit Parish [email protected] 920-450-6440 Kimberly WI WI 70 Green Bay 2022-10-04 Kim Moore One Voice Youth Ministry [email protected] 717-982-4699 Landisville PA 26 Harrisburg 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 | |
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Rahul Sharma | Bob | St. Fabian | Yes | 4 | Male | 3XL | Adult (21 and older) | (248) 747-2077 | 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 | 2 | 2 | No | 10/07/1973 | Michelle Darcy-Sharma | Spouse | (248) 227-9026 | Asthma, diabetes, arthritis (both knees) | Wixela (asthma), semglee (insulin), metformin (diabetes), ibuprofen (arthritis) | Dr Steven Klein | (248) 553-2200 | 01/19/2021 | Aetna | W267528727 | 868402-012-00001 | AGREE | AGREE | AGREE |  | AGREE | No | 278 | 1 | January 24, 2023 8:55 AM | |||||||||
Suraj Sharma | Sonny | St. Fabian | Yes | 2 | Male | Medium | Young Adult (18-20) | (248) 302-3919 | 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 | 2 | 4 | 1 | 2 | I would rather work on a building/construction project if possible | No | 01/19/2005 | Bob Sharma | Father | (248) 747-2077 | Eczema, asthma | Allegra (seasonal allergies), Singulair (asthma control), Triamcinolone ointment (eczema) Nasacort (seasonal allergies) | Dr Bethany Clary | (248) 553-2200 | 01/19/2021 | BC/BS OF MI | FSP916416217 | 87252 | AGREE | AGREE | AGREE |  | AGREE | No | 276 | 2 | January 24, 2023 8:49 AM | ||||||||
Arjun Sharma | AJ | St. Fabian | Yes | 6 | Male | Large | Adult (21 and older) | (248) 756-0824 | 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 | 3 | 4 | 3 | 2 | Asthma | 03/26/2001 | Rahul Sharma | Father | (248) 747-2077 | Asthma | Allegra 1 pill every 24 hours allergies Singulair 1 pill every 24 hours asthma | Bethany Clary | (248) 553-2200 | 06/21/2022 | Blue Cross Blue Shield of MI | FSP916416217 | 87252 | AGREE | AGREE | AGREE |  | AGREE | No | 275 | 3 | January 23, 2023 8:38 PM | |||||||||
Kyle Smart | St. Fabian | Yes | 1 | Male | Medium | Youth (under 18) | 12th | 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 | 4 | 1 | 1 | 10/19/2006 | Karen Smart | Parent | (248) 515-8643 | Dr. Irvin Kappy | (248) 661-8230 | 12/02/2019 | BCBS of Michigan | 83640 | GMJ920925299 | AGREE | AGREE | AGREE | Karen Smart |  | AGREE | 258 | 4 | January 23, 2023 8:09 AM | |||||||||||||
Nathan Smart | St. Fabian | Yes | 1 | Male | Large | Youth (under 18) | 10th | Work at a social service center (homeless shelter, food distribution center) | Work project (painting, indoor clean up, maintenance, repair work, outdoor yard work) | 1 | 1 | 1 | 2 | 1 | 1 | 11/24/2008 | Karen Smart | Mother | (248) 515-8643 | Dr. Irvin Kappy | (248) 661-8230 | 12/02/2019 | BCBS of Michigan | 83640 | GMJ920925299 | AGREE | AGREE | AGREE | Karen Smart |  | AGREE | 257 | 5 | January 23, 2023 8:06 AM | |||||||||||||
Carolyn Pankow | St. Fabian | Yes | 1 | Female | Small | Adult (21 and older) | (989) 948-1109 | 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 | 2 | 1 | 1 | Moderate home experience with basic power tools | 10/07/1993 | Brian & Catherine Pankow | parents | (989) 492-0076 | none | Dr. Shalini Signh | (248) 265-4160 | 08/20/2007 | Blue Cross Blue Shield | RYR922999994 | 71311 | AGREE | AGREE | AGREE |  | AGREE | No | 247 | 6 | January 21, 2023 11:08 AM | |||||||||||
Alex Rovinski | St. Fabian | Yes | 1 | Male | XL | Adult (21 and older) | (248) 914-2806 | Work project (painting, indoor clean up, maintenance, repair work, outdoor yard work) | Work at a social service center (homeless shelter, food distribution center) | 3 | 2 | 3 | 4 | 1 | 3 | 06/22/1989 | Mike Rovinski | Father | (248) 914-2526 | hypertension | Losartan Tartrate (100 mg, once daily) | Chris Gadoua | (248) 336-4000 | 11/14/2002 | BlueCross BlueShield of Illinois | NLB826002366 | PF1348 | AGREE | AGREE | AGREE |  | AGREE | No | 227 | 7 | January 19, 2023 9:42 PM | |||||||||||
Dominic Diego | Nick | St. Fabian | 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 | 1 | 1 | 2 | 1 | 1 | Mold allergy | 11/02/2008 | Joseph Diego | Father | (248) 613-7880 | Mold allergy Seasonal allergy | Cetirizine, 10mg | Dr. Neda Saker | (248) 435-9310 | 11/29/2019 | BCBS | R58878717 | 105 | AGREE | AGREE | AGREE | Maria Diego |  | AGREE | 225 | 8 | January 19, 2023 8:01 PM | ||||||||||
Gabriel Diego | Gabe | St. Fabian | No | 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 | Mold allergy | 01/18/2007 | Joseph Diego | Father | (248) 613-7880 | Mold allergy Seasonal allergy | Cetirizine, 10mg | Dr. Neda Saker | (248) 435-9310 | 10/19/2018 | BCBS | R58878717 | 105 | AGREE | AGREE | AGREE | Maria Diego |  | AGREE | 223 | 9 | January 19, 2023 7:59 PM | ||||||||||
Jordan Dallison | St. Fabian | Yes | 1 | Female | Medium | 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 | 2 | 4 | 1 | 1 | 12/28/2006 | Jasmine Marchong | Parent | (248) 408-3229 | Dr David Hug | (248) 477-5608 | 09/07/2018 | BCBS of MI | DZW890031034 | 82100 | AGREE | AGREE | AGREE | Jasmine Marchong |  | AGREE | 210 | 10 | January 19, 2023 6:38 PM | |||||||||||||
Cameron Dallison | Cameron | St. Fabian | Yes | 1 | Male | Small | 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) | 3 | 1 | 2 | 3 | 2 | 1 | 07/12/2008 | Jasmine Marchong | Parent | (248) 408-3229 | Seasonal allergies | None | Dr. David Hug | (248) 477-5608 | 08/27/2012 | BCBS of MI | Dzw890031034 | 82100 | AGREE | AGREE | AGREE | Jasmine Marchong |  | AGREE | 209 | 11 | January 19, 2023 6:27 PM | ||||||||||
Tomas Walmsley | Tomas | St. Fabian | Yes | 1 | Male | Medium | Youth (under 18) | 12th | 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 | 2 | 5 | 2 | 3 | 02/28/2023 | Brigitte Walmsley | Mom | (248) 921-5470 | Dr. Sylvera | (248) 539-7726 | 02/28/2016 | Blue cross blue shield ppo | Xyq920973904 | 007007692 | AGREE | AGREE | AGREE | Tomas Walmsley |  | AGREE | 208 | 12 | January 19, 2023 6:07 PM | ||||||||||||
Kurt Rodrigues | Kurt | St. Fabian | Yes | 1 | Male | Small | 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 | 2 | 3 | 1 | 1 | No | 10/24/2007 | Sharon Gonsalves | Mom | (248) 974-3206 | Dr. Ram | (248) 465-4847 | 11/13/2018 | Blue Cross Blue Shield | YFE829614825 | 073909 | AGREE | AGREE | AGREE | Sharon Gonsalves |  | AGREE | 207 | 13 | January 19, 2023 6:00 PM | |||||||||||
Joseph Lusk | Joey | St. Fabian | 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) | 1 | 1 | 1 | 2 | 1 | 1 | easy to work with | no | 10/24/2007 | Jennifer Lusk | mom | (248) 935-1408 | none | none | Robert Brateman | (248) 473-8580 | 11/15/2018 | BCBS | MDA920324101 | 71775 | AGREE | AGREE | AGREE | Jennifer Lusk |  | AGREE | 205 | 14 | January 19, 2023 5:35 PM | |||||||||
Elizabeth Sterling | Lizzy | St. Fabian | Yes | 2 | Female | Medium | Youth (under 18) | 12th | 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 | 3 | 1 | 1 | 09/11/2006 | Janice Sterling | mom | (812) 361-5743 | Dr. Miral | (248) 788-2100 | 06/01/2016 | Aetna | w100405565 | 701496-47-014 | AGREE | AGREE | AGREE | Janice Sterling |  | AGREE | 204 | 15 | January 19, 2023 5:23 PM | ||||||||||||
Isabella Sterling | Izzy | St. Fabian | No | Female | 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 | 1 | 1 | 3 | 1 | 1 | 08/26/2008 | Janice Sterling | mom | (812) 361-5743 | Dr. Miral | (248) 788-2100 | 09/18/2013 | Aetna | w100405565 | 701496-47-014 | AGREE | AGREE | AGREE | Janice Sterling |  | AGREE | 203 | 16 | January 19, 2023 5:19 PM | |||||||||||||
Julie Flory | St. Fabian | Yes | 1 | Female | Large | Adult (21 and older) | (734) 629-7275 | Work at a social service center (homeless shelter, food distribution center) | Work project (painting, indoor clean up, maintenance, repair work, outdoor yard work) | 1 | 1 | 1 | 4 | 1 | 1 | 09/27/1961 | Michael Flory | Spouse | (313) 378-8774 | None | Zyrtec - 10 mg - allergies Lipitor - 10 mg - cholesterol | Dr. Paul Patrick | (734) 398-7880 | 09/28/2022 | Blue Cross of Michigan | GMJ894705250 | 83640 | AGREE | AGREE | AGREE |  | AGREE | No | 201 | 17 | January 19, 2023 5:15 PM | |||||||||||
Braden Kendall | St. Fabian | Yes | 1 | Male | Medium | 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 | 3 | 1 | 1 | 03/06/2007 | Keri Kendall | Mother | (248) 615-0205 | isotretinoin, 40 mg, acne | Dr Parikh | (248) 465-4847 | 07/12/2018 | Aetna | W276704764 | 187807-012-00001 | AGREE | AGREE | AGREE | Keri Kendall |  | AGREE | 198 | 18 | January 19, 2023 5:05 PM | ||||||||||||
Kendal Lavigne | Keni | St. Fabian | Yes | 3 | Female | XL | Young Adult (18-20) | (248) 234-1680 | 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 | I’m very good with cistern and the elderly! | no | 08/28/2004 | Michelle Power | mother | (248) 787-3934 | Crista Shilling | (248) 454-9000 | 07/17/2021 | Anthem Blue Cross Blue Shield | HEXAN7479122 | 270158M3FA | AGREE | AGREE | AGREE |  | AGREE | 197 | 19 | January 19, 2023 4:57 PM | |||||||||||
Benjamin Kreucher | Ben | St. Fabian | Yes | 1 | Male | Medium | Adult (21 and older) | (248) 563-4637 | Work project (painting, indoor clean up, maintenance, repair work, outdoor yard work) | Work with children at day care centers for low-income families | 3 | 2 | 2 | 3 | 2 | 2 | 04/22/1984 | Walter Kreucher | Father | (248) 563-4635 | Marlene Kennerly | (800) 436-7936 | 08/13/2007 | Blue cross blue shield | 9101003777 | 71569 | AGREE | AGREE | AGREE |  | AGREE | No | 196 | 20 | January 19, 2023 4:49 PM | ||||||||||||
Victoria Raczkowski | Tori | St. Fabian | Yes | 3 | Female | Large | Young Adult (18-20) | (248) 310-7030 | Work with children at day care centers for low-income families | Work project (painting, indoor clean up, maintenance, repair work, outdoor yard work) | 2 | 2 | 1 | 5 | 1 | 1 | 01/10/2004 | Annette Raczkowski | Mother | (248) 320-8999 | Asthma Seasonal Allergies | Manisha Garg | (313) 359-0801 | 09/21/2015 | Blue Care Network | MiBCNRX | MiBCNRX | AGREE | AGREE | AGREE |  | AGREE | 195 | 21 | January 19, 2023 4:47 PM | ||||||||||||
Brennan McGrath | Brennan | St. Fabian | No | 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) | 1 | 1 | 1 | 2 | 1 | 1 | 02/16/2007 | Michaela McGrath | Mom | (248) 765-0777 | Bee Sting Allergy | Epi Pen | Dr Christa Shilling | (248) 454-9000 | 08/24/2022 | Blue Cross | MMJ890741684 | 71453 | AGREE | AGREE | AGREE | Michaela McGrath |  | AGREE | 194 | 22 | January 19, 2023 4:32 PM | |||||||||||
Stephanie Tierney | Stephanie | St. Fabian | Yes | 2 | Female | Large | Adult (21 and older) | (734) 272-5708 | Work at a social service center (homeless shelter, food distribution center) | Work with children at day care centers for low-income families | 2 | 1 | 2 | 4 | 1 | 1 | 02/22/1981 | Kim Witten | Sister | (313) 949-4866 | Mark Oberdoerster | (734) 981-3300 | 06/01/2016 | BCBS | JXP891659262 | 000071755 | AGREE | AGREE | AGREE |  | AGREE | No | 193 | 23 | January 19, 2023 4:23 PM | ||||||||||||
Becky Phillips | Holy Mother of Consolation | Yes | 3 | Female | Medium | Adult (21 and older) | (608) 501-7501 | 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 | 4 | 1 | 1 | 07/24/1983 | Nick Phillips | Husband | (608) 590-2147 | Halbersma | (608) 423-1100 | 01/03/2017 | WPS | 864003997 | WP112 | AGREE | AGREE | AGREE |  | AGREE | No | 178 | 24 | January 19, 2023 1:42 PM |