Required field(s) are indicated by an *. * MOM event in Select Wilmington April 26-27 Cullowhee July 12-13 Fayetteville July 26-27 Asheville August 2-3 Salisbury September 27-28 Dare Co. October 25-26 * First Name * Last Name
The fields "License Number", "License State of Issuance", "Professional Liability Carrier" and "Current Carrier Covers Volunteer Work" are only required for Licensed Dentists and Registered Dental Hygienists.
Dental Board License Number * License State of Issuance 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 DEA Number is needed for dentist volunteers that expect to write prescriptions. DEA Number Professional Liability Carrier * Current Carrier Covers Volunteer Work?
Yes
No
Not Applicable * Profession Select Dentist Dental Hygienist Dental Assistant Equipment Technician Laboratory Technician Dental Student Hygiene Student Assistant Student Lab Tech Student Nurse/ Nursing Student NCDS Staff * Specialty Select General Practice Oral & Maxillofacial Surgery Endodontist Orthodontist Pediatric Dentistry Periodontist Prosthodontist Oral Pathologist Public Health Oral & Maxillofacial Radiology N/A (DA, DH, TECH, Students) * Address 1 Suite * City * 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 * Zip * Email * Phone Number I pledge to be present for: Friday AM 6:00am-12:00pm
Friday PM 11:30am-5:00pm Saturday AM 6:00am-12:00pm
Saturday PM 11:30am-5:00pm * I prefer to do Select Whatever Is Needed Extractions Restorations Cleanings Assisting Triage Radiography (Dexis Experience Required) Sterilization Supplies Maintenance Laboratory NCDS Staff
• Radiography needs volunteers with Dexis experience.
Dentists, would you be willing to provide care for "Post Clinic Emergency Follow Up"?
* Not Applicable Not at this time Yes! My office number is 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. * Name * Date (MM/DD/YYYY)
