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
2022-10-24EmilyRauserSt. Pius X[email protected]2032556134FairfieldCT30Bridgeport
2022-10-21BryannaUrsoAll Saints (PA)[email protected]724-287-1759ButlerPA35Pittsburgh
2022-10-13ErinJohnsonSt. Mary of Sorrows[email protected]5405338237FairfaxVA18Arlington
2022-10-05MicheleMcPheelyImmaculate Heart of Mary[email protected]812-454-7143AtlantaGA30Archdiocese of Atlanta
2022-10-05LynnPechineyAll Saints (VA)[email protected]7033932141ManassasVA65Arlington
2022-10-05KatieBooselNorthern Butler County Catholic Churches[email protected]7249531669Slippery RockPA18Pittsburgh
2022-10-04MicheleLanutiMother Teresa Catholic Church[email protected]919-656-9979CaryNC30Diocese of Raleigh, N.C

Total quantity sold : 226

Email selected customers

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Camper Paperwork (AKA Applications)

Participant NameNicknameFirst Choice Service AssignmentHave 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
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
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
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
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
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
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
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
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
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
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
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
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
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