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.

Note: Community volunteers must be age eighteen or older. Volunteers under age eighteen can volunteer for Thursday set up and/or Saturday tear down only.

Required field(s) are indicated by an *.
* MOM event in	Please selectWilmington April 26-27Cullowhee July 12-13Fayetteville July 26-27Salisbury September 27-28Dare County October 25-26
* First Name
* Last Name
* Street or PO Box
Suite
* City
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I pledge to be present for (select all that apply):
* Preference 1	SelectUnload Trucks and Set Up ClinicVolunteer RegistrationDirect Traffic and ParkingPatient GreeterPatient RegistrationSpanish-English TranslatorsTriage ScribesPatient Escorts RunnersTrash DisposalPatient CheckoutFood ServiceTear-Down Clinic and Load Supply Trucks Please select your first choice
* Preference 2	SelectUnload Trucks and Set Up ClinicVolunteer RegistrationDirect Traffic and ParkingPatient GreeterPatient RegistrationSpanish-English TranslatorsTriage ScribesPatient EscortsRunnersTrash DisposalPatient CheckoutFood ServiceTear-Down Clinic and Load Supply Trucks Please select your second choice
* Preference 3	SelectUnload Trucks and Set Up ClinicVolunteer Registration Direct Traffic and Parking Patient GreeterPatient RegistrationSpanish-English TranslatorsTriage ScribesPatient EscortsRunnersTrash DisposalPatient CheckoutFood ServiceTear-Down Clinic and Load Supply Trucks Please select your third choice
	Thursday Set up: 10:30 AM - 5:00 PM
	Friday 6:00 AM - 12:00 PM Friday 11:30 AM - 5:00 PM
	Saturday 6:00 AM - 12:00 PM Saturday 11:30 AM - 5:00 PM
	Saturday Tear down: 3:00 PM - Until
"Clinic ending times and breakdown on Saturday vary depending on the size of the clinic."
Comment
I understand there is potential risk for exposure to bloodborne pathogens (BBP's) including human immunodeficiency virus (HIV), hepatitis B virus (HBV), and hepatitis C virus (HCV), as well as other bacteria, protozoa, viruses and prions during the performance of my volunteer service at this NCMOM 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 Health Fund for any of my expenditures.
* Name
* Date	/ / (MM/DD/YYYY)