Group List
Total quantity sold : 226 Date Billing First name Billing Last name Billing Company Billing E-mail Billing Phone Billing City Billing State Variation Order Qty Total _billing_diocese 2022-10-24 Emily Rauser St. Pius X [email protected] 2032556134 Fairfield CT 30 Bridgeport 2022-10-21 Bryanna Urso All Saints (PA) [email protected] 724-287-1759 Butler PA 35 Pittsburgh 2022-10-13 Erin Johnson St. Mary of Sorrows [email protected] 5405338237 Fairfax VA 18 Arlington 2022-10-05 Michele McPheely Immaculate Heart of Mary [email protected] 812-454-7143 Atlanta GA 30 Archdiocese of Atlanta 2022-10-05 Lynn Pechiney All Saints (VA) [email protected] 7033932141 Manassas VA 65 Arlington 2022-10-05 Katie Boosel Northern Butler County Catholic Churches [email protected] 7249531669 Slippery Rock PA 18 Pittsburgh 2022-10-04 Michele Lanuti Mother Teresa Catholic Church [email protected] 919-656-9979 Cary NC 30 Diocese of Raleigh, N.C Email selected customers
No records found
No records found
No records found
| Participant Name | Nickname | First Choice Service Assignment | 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 | |
|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|
Rebekah Nolan | Work project (painting, indoor clean up, maintenance, repair work, outdoor yard work) | Yes | 2 | Female | Small | Youth (under 18) | 10th | 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 | 2 | I would like to be put into a talkative group. | None | 04/03/2008 | Troy Nolan | Father | (703) 801-5999 | None | Sertraline 25 MG Bupropion 75 MG | Haymarket Pediatrics | (703) 753-1895 | 01/01/2017 | United Healthcare | 907055947 | 2F5059 | AGREE | AGREE | AGREE | Valerie Nolan |  | AGREE | 360 | 1 | January 28, 2023 2:13 PM | |||||||||
Grace Karcher | Work with children at day care centers for low-income families | No | Female | Large | 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 | 3 | 1 | 1 | Very allergic to dust | 06/17/2009 | Camille Karcher | Mom | (703) 853-5216 | Allergies | Allegra allergy medicine | Docor White | (703) 257-8090 | 08/11/2021 | Anthem BCBS | YTN989M76616 | M07675 | AGREE | AGREE | AGREE | Camille Karcher |  | AGREE | 353 | 2 | January 27, 2023 5:05 PM | |||||||||||
Robin Dalusung | Mia | Work with children at day care centers for low-income families | No | Female | Medium | Youth (under 18) | 11th | 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 | 2 | 1 | 1 | 02/09/2007 | Robin Dalusung | Grandmother/guardian | (571) 275-4724 | Dr. Perez | (703) 368-3161 | 09/06/2011 | United Health CAre | 911-87726-04 | 904646 | AGREE | AGREE | AGREE | Robin Dalusung |  | AGREE | 350 | 3 | January 27, 2023 2:00 PM | |||||||||||||
Ashton Hargus | Work project (painting, indoor clean up, maintenance, repair work, outdoor yard work) | Yes | 1 | Female | 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 | 4 | 1 | 1 | 08/14/2007 | Carolyn Kinney | Parent | (703) 789-5709 | Dr. Katz | (703) 330-3939 | 01/16/2019 | Cigna | U5150321403 | 3170520 | AGREE | AGREE | AGREE | Carolyn Kinney |  | AGREE | 348 | 4 | January 27, 2023 11:37 AM | |||||||||||||
Kyleigh Fifield | Work with children at day care centers for low-income families | No | Female | Small | 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 | 2 | 1 | 1 | 11/25/2008 | Lindsay Fifield | Mom | (650) 465-3079 | mortin for headaches | Gail Dolan | (571) 379-4246 | 01/22/2018 | Anthem Blue Cross | ENA363W06635 | 1867CE | AGREE | AGREE | AGREE | Lindsay Fifield |  | AGREE | 346 | 5 | January 27, 2023 8:08 AM | |||||||||||||
Thomas Reynolds | Tommy | Work project (painting, indoor clean up, maintenance, repair work, outdoor yard work) | Yes | -2 | Male | 3XL | Adult (21 and older) | (170) 396-3128 | 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 | 3 | 2 | 10/26/1978 | Frances Reynolds | Spouse | (703) 963-4232 | pantoprozole 40mg | Gary DeRosa | (703) 368-3161 | 01/10/2012 | Blue Cross Blue Shield | R58754202 | 105 | AGREE | AGREE | AGREE |  | AGREE | No | 344 | 6 | January 26, 2023 11:02 PM | |||||||||||
Ella Happ | Work at a social service center (homeless shelter, food distribution center) | No | Female | Medium | Youth (under 18) | 9th | 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 | Exercise- induced asthma, must take inhaler 15 minutes before heavy exercise | 08/18/2008 | Kathleen Mirus | mother | (540) 630-1372 | Asthma, tree nut allergy, depression | Fluoxetine 40 mg daily for depression, Arnuity inhaler 1 puff daily for Asthma, Cetirizine 10 mg daily for allergies. Has an Epi-Pen in case of tree nut ingestion. Has an Albuterol inhaler that she needs to take one puff 15 minutes prior to physical exercise. | Dr. Tamandong- PediatriCare | (703) 330-3939 | 08/26/2020 | Blue Cross Blue Shield Illinois | KJG807134532 | PA3677 | AGREE | AGREE | AGREE | Kathleen Mirus |  | AGREE | 341 | 7 | January 26, 2023 7:50 PM | |||||||||||
Peter Lasseter | Work project (painting, indoor clean up, maintenance, repair work, outdoor yard work) | No | Male | Medium | Youth (under 18) | 9th | 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 | 12/30/2008 | Leticia Lasseter | Mother | (443) 804-8300 | Food Allergies Nuts and Fish | The Pediatric Group | (703) 971-6900 | 03/15/2021 | Aetna | W2764 26663 | 868403-018 00002 | AGREE | AGREE | AGREE | Leticia Lasseter |  | AGREE | 339 | 8 | January 26, 2023 7:35 PM | |||||||||||||
Michael Zahorchak | Work project (painting, indoor clean up, maintenance, repair work, outdoor yard work) | No | Male | Medium | Youth (under 18) | 9th | 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 | 08/07/2008 | Theresa Zahorchak | Parent | (703) 507-6363 | Dr. Katz | (703) 330-3939 | 08/27/2019 | United Healthcare | 987134107 | 1493092 | AGREE | AGREE | AGREE | Theresa Zahorchak |  | AGREE | 335 | 9 | January 26, 2023 6:05 PM | ||||||||||||||
Aidan Ragland | Work project (painting, indoor clean up, maintenance, repair work, outdoor yard work) | Yes | 1 | Male | Large | 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 | 2 | 3 | 1 | 1 | no | 09/29/2007 | Stephanie Oetjen | mother | (571) 577-7245 | none | none | Dr SHINAISHIN | (703) 753-6772 | 11/30/2017 | ANTHEM | JUG0124406MB | JNT024 | AGREE | AGREE | AGREE | Stephanie Oetjen |  | AGREE | 333 | 10 | January 26, 2023 4:36 PM | ||||||||||
William Reynolds | Work project (painting, indoor clean up, maintenance, repair work, outdoor yard work) | Yes | 1 | Male | Large | Youth (under 18) | 10th | 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 | 2 | 1 | 1 | 08/07/2008 | Tommy Reynolds | Father | (703) 963-1281 | Dr granados | (703) 369-2999 | 06/16/2020 | FEP BCBS | R58754202 | 105 | AGREE | AGREE | AGREE | Fuzzy Reynolds |  | AGREE | 329 | 11 | January 26, 2023 2:33 PM | |||||||||||||
CECILIA DALY | Work with children at day care centers for low-income families | No | Female | Medium | Youth (under 18) | 9th | Work with children at day care centers for low-income families | Work at a social service center (homeless shelter, food distribution center) | 1 | 1 | 2 | 3 | 1 | 1 | 07/21/2023 | Rebekah Daly | Mom | (202) 841-1578 | VanderWoode | (703) 229-4827 | 07/01/2022 | Cigna | U7637674608 | 3343660 | AGREE | AGREE | AGREE | Rebekah Daly |  | AGREE | 326 | 12 | January 26, 2023 1:56 PM | ||||||||||||||
Theresa Zahorchak | Work at a social service center (homeless shelter, food distribution center) | Yes | 1 | Female | Small | Adult (21 and older) | (703) 507-6363 | 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 | None | Associate Staff: Stay at home base and work behind the scenes with the HEART staff. ,Troubleshooter: Assist multiple work teams during the week | 01/28/1974 | Mike Zahorchak | Spouse | (703) 507-5973 | None | None | Dr. White | (703) 257-8090 | 12/08/2019 | United healthcare | 987134106 | 1493092 | AGREE | AGREE | AGREE |  | AGREE | No | 323 | 13 | January 26, 2023 1:27 PM |