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NC MOM Pre-Dental Student Volunteer Registration Form

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. Descriptions for each volunteer position are shown below.
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 your school from the list below and answer the following questions appropriately. Select "Other" and provide the name of your school if it is not displayed.

Please note school/class if "Other" was selected
Job descriptions can be found at bottom of this form. Please select job preferences below. Jobs will ultimately be filled on a first come first serve basis but preferences may be taken into account when spots are available.
I prefer to do:

Have you attended a NC MOM clinic before?

Do you have your Hepatitis B Vaccination?

  • 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.

I pledge to be present for: (Multiple selections are welcome)

Thursday Set Up:

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.

Job Descriptions:

1. Unload Trucks and Set Up Clinic (Thursday): Help unload NC MOM supply trucks at site and set up clinic areas with portable dental equipment as directed by NC MOM personnel. Set up tables and chairs, lay out electric cords and air compressor hoses, put up signs etc. and anything else that needs to be done. 

2. Friday and Saturday Set Up: Prepare the clinic floor each morning for patients. Check equipment function at each operatory. Assist setting up sterilization area for each day. Fill operatory units with fresh water and resupply disinfecting materials to clinic tables. Perform final disinfecting wipe of all chairs and surfaces before providers and patients enter clinic. 
3. Triage Scribes: Records examination comments and instructions as directed by the Triage Dentist; assists and performs small errands as directed by the Triage Dentist.
4. Radiology: Disinfect equipment between patient X-Rays, direct patient flow and paperwork into and out of radiology bus. If you are a certified X-Ray Technician and have experience with dental X-Rays, please note this in your registration.
5. Water: Manage distilled water supply and refill water bottles for dental units throughout clinic. Manage bleach solution used at tables to disinfect between patients and disinfect at end of clinic.
6. Supplies (Red Side): Disinfect patient supply tackle boxes returned to red table by dentist/assistant/hygienist. Must monitor returned supplies and disposables. Disinfected boxes will be transferred to White Supply for refill.
7. Supplies (White Side): Refill tackle boxes with disposable supplies for each procedure. Maintain supply of disposable Personal Protective Equipment (PPE) and disinfecting wipes and resupply as needed.
8. Sterilization (Red Side): Accept incoming instruments from the clinic floor and manage flow of pre-cleaning instruments before loading in autoclaves. Load and unload Biosonics, bag instruments, repack cassettes and wrap for sterilization in autoclave.
9. Sterilization (White Side): Organize instruments for pickup after sterilization in autoclave. Manage flow of instruments and cassettes as needed by providers.
10. Operatory Management: Provide support to dentist, hygienist and assistants on the floor. Return used instruments and supplies to red side and wipe and disinfect operatories between patients. Assist local volunteers with patient flow from waiting area to patient chair. Eliminate solid and liquid waste as needed at operatories with help of other volunteers.
11. Trash Disposal: Dispose of solid waste throughout event. Will need to wear disposable Personal Protective Equipment (provided at the clinic). Pre-Dental Student Volunteers and NCMOM Staff will assist in trash disposal. Should have Hepatitis B vaccine. Confirm disposal location and routines with Facilities Team.
12. Unit/Suction Monitor: Monitor the clinic floor for issues with portable dental units. Monitor unit water levels and suction bottle levels (replacing/emptying as needed). Reporting any leaks or problems to a NC MOM staff member.
13. Clinic Pack Up (Saturday Afternoon): Help disinfect and disassemble equipment, pack up supplies, and load supply trucks as directed by NC MOM personnel. This process begins while final patients are seated and is usually complete by 8 p.m. on Saturday.