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
2023-01-18MaddiePikusCalvert Hall College High School[email protected]9087211400BaltimoreMD10Baltimore
2022-10-19AllisonFurnaldSt. Lawrence The Martyr Church[email protected]4848944155ChesterNJ24Paterson
2022-10-05JaniceDagneyOur Lady of Consolation Early Learning Center[email protected]484-995-4715ParkesburgPA16Philadelphia
2022-10-05MelissaBoyleSt. Jane France[email protected]4102554646pasadenaMD16Baltimroe
2022-10-05StephanieTierneySt. Fabian[email protected]248.921.0442Farmington HillsMI35Archdiocese of Detroit
2022-10-05BeckyPhillipsHoly Mother of Consolation[email protected]608-835-5764OregonWI35Madison
2022-10-05SarahElmerHoly Spirit Parish[email protected]920-450-6440Kimberly WIWI70Green Bay
2022-10-04KimMooreOne Voice Youth Ministry[email protected]717-982-4699LandisvillePA26Harrisburg

Total quantity sold : 232

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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
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
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
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
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
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
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
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
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
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
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
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
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
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
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
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
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
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
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
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
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
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
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
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
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