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.

Required field(s) are indicated by an *.
* MOM event in	Please selectWilmington April 26-27Cullowhee July 12-13Fayetteville July 26-27Salisbury September 27-28Dare Co. October 25-26
* First Name
* Last Name
* Hepatitis B Vaccination	Select OneYesNo
* Street or PO Box
Suite
* City
* State	Select a StateOutside United StatesAlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWashington, D.C.West VirginiaWisconsinWyoming
* Zip
* Email
* Phone Number
* Emergency Contact Name
* Emergency Phone
* First MOM	Yes No
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."
Skills:	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.
* University
Faculty Advisor
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)