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
2022-10-07ChristineLamolinaraSt Andrew by the Bay[email protected]410-974-4366ANNAPOLISMD25Baltimore
2022-10-06MatthewLopinaSt. Pius X[email protected]336-272-4681GreensboroNC18Charlotte
2022-10-05JennBarlowHoly Family[email protected]336-778-0600Winston-SalemNC10Charlotte
2022-10-05JenniferNiemanSt Kateri Tekakwitha[email protected]757-766-3800YorktownVA25Richmond
2022-10-05TheresaBraderTransfiguration Catholic Church[email protected]7709771442MariettaGA20Atlanta

Total quantity sold : 98

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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
Matthew Lopina
Matt
St. Pius X
Yes
1
Male
Medium
Adult (21 and older)
(336) 409-4333
Work project (painting, indoor clean up, maintenance, repair work, outdoor yard work)
Work at a social service center (homeless shelter, food distribution center)
4
1
4
4
1
1
No
No
Associate Staff: Stay at home base and work behind the scenes with the HEART staff. ,Troubleshooter: Assist multiple work teams during the week
12/01/1980
Erika Lopina
Spouse
(336) 565-6520
None.
None.
Dr. Bartholomew Lopina
(828) 465-3928
08/01/2021
BCBSNC
RGF103531617
14164309
AGREE
AGREE
AGREE
AGREE
No
183
1