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NCDSF MOM Volunteer Sign-up (Community)
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NCDSF MOM Volunteer Sign-up (Community)
NCDSF MOM Volunteer Sign-up (Community Volunteer)
NCDSF MOM Community Volunteer Registration Form
With your help, we expect to treat hundreds of patients in two days — thank you for volunteering! Volunteer jobs may require standing or walking for long periods of time, and some jobs may involve lifting/carrying heavy objects or working outside. Descriptions for each volunteer position are shown below.
Upcoming Clinics
*
--
--
High Point Clinic: March 27-28 (March 26 is Setup and Triage)
Please select the MOM clinic that you will volunteer for.
Name
*
First
Last
Address
*
Street Address
Address Line 2
City
Alabama
Alaska
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District of Columbia
Florida
Georgia
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Ohio
Oklahoma
Oregon
Pennsylvania
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
Armed Forces Americas
Armed Forces Europe
Armed Forces Pacific
State
ZIP Code
Email
*
Enter Email
Confirm Email
Please check for accuracy as this will be the email used for confirmation.
Phone
*
Are you a NCDS/ADA Member?
*
Yes
No
Not Sure
If you are a MEMBER, please enter your 9 Digit ADA Number.
Below this form is a list of Community Volunteer Job Descriptions. In an effort to assign Volunteers in an efficient manner, please select job preferences from the list below.
I prefer to do:
*
Unload Trucks and Set Up Clinic
Volunteer Registration
Patient Registration
Spanish-English Translators
Health History and Blood Pressure Screening
Triage Volunteers
Patient Flow
Treatment Waiting Area Receptionist
Runner/Errands
Trash Disposal
Patient Checkout
Data Entry
Tear Down Clinic and Load Supply Truck
Parking Lot and Traffic Control
Whatever is Needed
Additional Notes/Skills:
I pledge to be present for: (Multiple shift selections are welcome)
Please select each time slot you are volunteering for. Select "N/A" for times that you are unable to attend. PRINT OFF THE COMPLETED FORM PRIOR TO SUBMITTING FOR FUTURE REFERENCE Upon submitting, your registration for those date(s) & time(s) is automatically confirmed.
Thursday (Setup):
*
9:00 AM -- 2:30 PM
11:30 AM -- 5:00 PM
N/A
Friday Morning (Full)
FULL
Friday Afternoon (Full):
FULL
Saturday Morning (Full):
FULL
Saturday Afternoon (Full):
FULL
*
I agree to this consent.
I understand there is potential risk for exposure to bloodborne pathogens (BBP's) including human immunodeficiency virus (HIV), hepatitus B virus (HBV), and hepatitus C virus (HCV), as well as other bacteria, protozoa, viruses and prions during the performance of my volunteer service at this NCDSF MOM project. I understand that I am personally responsible for any medical fees and services associated with a percutaneous piercing wound typically set by a needle point, but possibly by other sharp instruments or objects.
I understand that this is a donation of my services and that I am responsible for my own travel, accommodations, meals and medical care. I also understand that I am not entitled to reimbursement from the Dental Society or the NC Dental Society Foundation for any of my expenditures.
Name
*
First
Last
Date
*
Date Format: MM slash DD slash YYYY
MOM Job Descriptions - Community Volunteer
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