Required field(s) are indicated by an *.
* MOM event in Please select Dare Co. October 25-26 Charlotte, Sept. 5-6 Winston Salem, Nov. 14-15
* First Name
* Last Name
* Hepatitis B Vaccination Select One Yes No
* Street or PO Box
* State Select a State Outside United States Alabama Alaska Arizona Arkansas California Colorado Connecticut Delaware 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 Washington, D.C. West Virginia Wisconsin Wyoming
* Phone Number
* Emergency Contact Name
* Emergency Phone
* First MOM
Previous MOM Positions
Thursday Set up: 10:30 AM - 5:00 PM
Friday 6:00 AM - 1:00 PM
Friday 12:00 PM - 7:00 PM
Saturday 6:00 AM - 1:00 PM
Saturday 12:00 PM - 7:00 PM
Saturday Breakdown 3:00 PM - Until
"Clinic ending times and breakdown on Saturday vary depending on the size of the clinic."
Dental Training or Language Skills
Post graduate students preparing to apply for dental school should state "Post Graduate, School Name" and enter "not applicable" in the faculty advisor name field.
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.
* Date / / (MM/DD/YYYY)