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NC Dental Foundation
NCDSF MOM Volunteer Sign-up (Medical Professionals)
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NCDSF MOM Volunteer Sign-up (Medical…
NCDSF MOM Volunteer Sign-up (Medical Professional)
NCDSF MOM Medical Professional Volunteer Registration Form
While all necessary supplies will be furnished, professionals are encouraged to have their assistant or team attend (please have them sign up separately).
High Point Clinic: March 27-28 (March 26 is Setup and Triage)
Please select the MOM clinic that you will volunteer for.
Address Line 2
District of Columbia
Armed Forces Americas
Armed Forces Europe
Armed Forces Pacific
Please check for accuracy as this will be the email used for confirmation.
Are you a NCDS/ADA Member?
If you are a MEMBER, please enter your 9 Digit ADA Number.
Please select a profession and answer the following questions appropriately. Select "Other" if no other choice is applicable.
Licensed Practical Nurse
Certified Nursing Assistant
Please note profession if "Other" was selected.
I prefer to do:
Take Blood Pressure
Whatever is Needed
This section is completed by licensed volunteers. Volunteers need to provide their DEA number in order to write prescriptions.
Students/non-licensed volunteer please write "N/A/".
Professional Liability Carrier:
Students/non-licensed volunteer please write "N/A/". If you are a Military volunteer, please write "US Military". If you hold another coverage, please specify in the space above.
Will your current professional liability carrier cover this volunteer work?
If "No", please provide a copy of your policy provisions indicating that such volunteer activities are not covered. You may be eligible for free coverage for these volunteer activites through a special program administered by the NC Dental Society and provided to you at no charge by Medical Protective.
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.
7:30 AM -- 2:30 PM (Setup)
2:00 PM -- 5:00 PM (Triage)
6:00 AM -- 12:00 PM
11:30 AM -- 5:00 PM
6:00 AM -- 12:00 PM
11:30 AM -- End of Day
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.
Date Format: MM slash DD slash YYYY
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