Group List
Total quantity sold : 98 Date Billing First name Billing Last name Billing Company Billing E-mail Billing Phone Billing City Billing State Variation Order Qty Total _billing_diocese 2022-10-07 Christine Lamolinara St Andrew by the Bay [email protected] 410-974-4366 ANNAPOLIS MD 25 Baltimore 2022-10-06 Matthew Lopina St. Pius X [email protected] 336-272-4681 Greensboro NC 18 Charlotte 2022-10-05 Jenn Barlow Holy Family [email protected] 336-778-0600 Winston-Salem NC 10 Charlotte 2022-10-05 Jennifer Nieman St Kateri Tekakwitha [email protected] 757-766-3800 Yorktown VA 25 Richmond 2022-10-05 Theresa Brader Transfiguration Catholic Church [email protected] 7709771442 Marietta GA 20 Atlanta 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 | |
|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|
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 | January 19, 2023 2:21 PM |