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
2022-10-06jenniferRosherSt. Thomas[email protected]5086979528East BridgewaterMA48Boston
2022-10-05DebbieKitchenOur Lady of the Fields[email protected]4107332770MillersvilleMD20Archdiocese of Baltimore
2022-10-05TheresaAndaryPrince of Peace[email protected]2317443321MuskegonMI9Grand Rapids
2022-10-05ChristineFolsom-KovarikMary, Mother of God[email protected]9082298909HILLSBOROUGHNJ16Metuchen
2022-10-05SheilaBauerApple Valley Catholic Community[email protected]978-263-4305ActonMA50Boston
2022-10-05MicheleHardingChurch of the Assumption[email protected]2032228486WestportCT16Bridgeport, CT
2022-10-05NicolausSchmitzSt. Lawrence[email protected]6782403072LawrencevilleGA35Atlanta
2022-10-03AllisonProvinsalFiat Ventures[email protected](973) 500-3300WarrenNJ75Metutchen
2022-10-03BrianFlanaganSt. James[email protected](908) 280-1865Basking RidgeNJ49Metuchen
2022-09-30LindaDarlingHoly Cross Church[email protected]3026745787DoverDE35Wilmington

Total quantity sold : 353

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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
Rev. Steven Restrepo
St. Thomas
Yes
1
Male
Medium
Adult (21 and older)
(857) 413-6665
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
If I can be placed in an assignment with Jen Rosher the leader of the St. Thomas group that would be helpful.
Priest: Help with Liturgy/Reconciliation & go to a worksite
04/01/1993
Kacthary Sanclemente
Cousin
(617) 818-5012
Dr. Patricio Cabral
(857) 307-2200
11/26/2019
Tufts Health Plan
992557175
01
AGREE
AGREE
AGREE
AGREE
Yes
Priest
356
1
Reese Porro
St. Thomas
No
Female
Medium
Youth (under 18)
9th
Work with children at day care centers for low-income families
Work project (painting, indoor clean up, maintenance, repair work, outdoor yard work)
1
1
1
1
1
1
Sensitivity to heat and sun
03/16/2009
Katie Porro
Mom
(617) 794-6052
Dr Victoria Tan
(508) 584-1234
04/11/2014
Blue Cross Blue Shield Anthem
U2N675W03403
270113M0A0
AGREE
AGREE
AGREE
Katie Porro
AGREE
355
2
Katie Porro
St. Thomas
No
Female
Medium
Adult (21 and older)
(617) 794-6052
Work with children at day care centers for low-income families
Work project (painting, indoor clean up, maintenance, repair work, outdoor yard work)
1
1
1
3
1
1
Sensitivity to heat and sun
12/15/1978
Matt Porro
Spouse
(508) 944-3327
Dr Dyan Bhatia
(508) 350-2300
01/01/1990
Blue Cross Blue Shield Anthem
U2N675W03403
270113M0A0
AGREE
AGREE
AGREE
AGREE
No
354
3
Jonathon Murphy
Jack
St. Thomas
No
Male
Medium
Young Adult (18-20)
(774) 506-0846
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
3
2
2
08/30/2004
Mj Murphy
Mother
(508) 245-6763
David Chung
(508) 584-1210
09/09/2009
BCBS
MTN983129888
O
AGREE
AGREE
AGREE
AGREE
No
347
4
Linda Howard
St. Thomas
Yes
1
Female
Medium
Adult (21 and older)
(508) 942-6215
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
Associate Staff: Stay at home base and work behind the scenes with the HEART staff. 
07/08/1963
Tom Howard
husband
(508) 989-7132
Good Health
Synthroid 100 mcg daily
Dr. Kathleen Gilson
(508) 941-0497
07/29/2021
Blue Cross Blue Shield
MTP981489780
004000989
AGREE
AGREE
AGREE
AGREE
No
274
5
Jacob Howard
St. Thomas
Yes
1
Male
Medium
Youth (under 18)
11th
Work project (painting, indoor clean up, maintenance, repair work, outdoor yard work)
Work project (painting, indoor clean up, maintenance, repair work, outdoor yard work)
3
3
1
3
3
3
12/14/2006
Linda Howard
Mother
(508) 942-6215
Doctor Kevin Murphy
(508) 584-1210
02/09/2018
Blue Cross Blue Shield
MTP981489780
004000989
AGREE
AGREE
AGREE
Linda Howard
AGREE
273
6
Drew Silvia
St. Thomas
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
3
2
2
2
2
1
Interest in construction
None
04/13/2009
Sarah Silvia
Mother
(774) 259-2522
None
None
Dr Fred Kern
(508) 697-8116
06/20/2022
Harvard Pilgrim
HP2553771
HP2553771
AGREE
AGREE
AGREE
Sarah Silvia
AGREE
248
7
Noah Gibson
St. Thomas
No
Male
Large
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)
4
2
1
4
1
1
I'm a boy scout.
No.
08/08/2007
Kimberly Gibson
mother
(508) 596-9387
None
None
Dr. Britt Pena
(508) 584-6060
08/20/2018
Blue Cross Blue Shield MA
XXP983830447
002347905
AGREE
AGREE
AGREE
Kimberly Gibson
AGREE
224
8
Jennifer Rosher
Jen
St. Thomas
Yes
4
Female
Small
Adult (21 and older)
(617) 828-9147
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
2
3
None
No
10/20/1976
Brian Rosher
Husband
(617) 594-6903
Migraines
Methocarbamol, Rizatriptan, Nabumetone
Mrecia
(508) 350-2300
06/12/2017
BCBS
UEW983199803
None
AGREE
AGREE
AGREE
AGREE
No
206
9
Brett Schmitz
Brett
St. Lawrence
No
Female
Small
Youth (under 18)
8th
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
1
1
1
not very tall
allergic to blueberries
09/21/2009
Nic Schmitz
Dad
(706) 818-9401
none
epipen if she eats blueberries
Dr. Melissa Martin
(706) 548-7909
09/21/2012
Meritain Health
3619666926
10974
AGREE
AGREE
AGREE
Nic Schmitz
AGREE
202
10
Nic Schmitz
Nic
St. Lawrence
Yes
5
Male
2XL
Adult (21 and older)
(706) 818-9401
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
3
1
1
n/a
Had Lower back surgery
Associate Staff: Stay at home base and work behind the scenes with the HEART staff. 
01/25/1979
Jessica Schmitz
Wife
(678) 677-6950
Lower Back Surgery
None
Dr. Richard Maxa
(697) 597-3180
05/27/2022
Meritain Health
3619666926
10974
AGREE
AGREE
AGREE
AGREE
No
184
11