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NC MOM Dental Professional Volunteer Registration Form

While all necessary supplies will be furnished, Dental Professionals are encouraged to have their chair-side assistant attend (please have them sign up separately).
Clinic Selection: (Please make your selection. Registration for additional clinic dates will open approximately one month prior to the scheduled event. Additional dates require an additional form submission.)


Please check for accuracy as this will be the email used for confirmation.

Please select a profession and answer the following questions appropriately. Select "Other" if no other choice is applicable.

Profession:







Please not specialty if "Other" was selected
I prefer to do:









Dentist, would you be willing to provide care for "Post Clinic Emergency Follow Up?"


This section is completed by licensed dentist and hygienist volunteers. Volunteer dentists need to provide their DEA number in order to write prescriptions.

Students/non-licensed volunteers please write "N/A"
(e.g "NC") Students/non-licensed volunteers please write "N/A"
Students/non-licensed volunteers please write "N/A"
Students/non-licensed volunteers 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?


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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 activities 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.  
  • Upon submitting, your registration for those date(s) & time(s) is automatically confirmed.
  • Select "N/A" for times that you are unable to attend.
Thursday:


Friday Morning:


Friday Afternoon:


Saturday Morning:


Saturday Afternoon:


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.

"State":"NC"