Hope Smiles Volunteer Application-Sumner Center Outreach Nashville, January 13, 2024

1
Name* This field is required.
First Name
Last Name
2
What's the best email address for you?* This field is required.
3
What is the best number to reach you?* This field is required.
Area Code
Phone Number
4
Is this your first time to serve with Hope Smiles?* This field is required.
YESNO
5
We are excited to serve with you! What type of volunteer are you?* This field is required.
DDS/DMD
RDH
RDA
EFDA
Student
General/Admin
Set Up/Tear Down **Men of Valor**
Nurse
6
What type of student are you?* This field is required.
Dental School Student
RDA Student
RDH Student
Other
7
Name on Dental License (please leave blank if you are not a dentist)
First Name
Last Name
8
What is your t-shirt size?* This field is required.
XS
S
M
L
XL
2XL
3XL
9
What year are you in dental school?* This field is required.
1st year
2nd Year
3rd year
4th Year
Not a Dentist
10
Where are you enrolled in school?
11
If you are currently employed, please list your employer or practice affiliation:
12
Do you speak another language aside from English?
YESNO
13
What dental procedures are your comfortable performing?Our dental days will typically consist of extractions and minor restorative work. However, we’d love to know what other procedures you specialize in as we continue to grow and consider providing more services.
Huge
Large
Normal
Small
Ok
Ok
14
Will you be bringing a Dental Assistant from your office to serve with us?
YESNO
15
Please provide the first and last name of the Dental Assistant you are planning to bring from your office to serve with us.
First Name
Last Name
16
Please provide their email so that we can add them to the communication list to receive outreach details and reminders.
example@example.com
17
Great! Which language(s) do you speak?
18
Are there any dental professionals in your community that you think would be interested in joining us? Please let us know their name and email so that we can reach out.
Huge
Large
Normal
Small
Ok
Ok
19
Emergency Contact Name and Relationship* This field is required.
20
Emergency Contact Number* This field is required.
Area Code
Phone Number
21
Are you licensed to deliver local anesthesia* This field is required.
YESNO
22
Hygiene Volunteers: We will need a copy of your license. This can be a photo taken from your phone or a digital version, whichever is easier. Are you ready to upload these now or do you want to do it later?* This field is required.**This document is required for you to volunteer with Hope Smiles so if you do not upload it now we will be sending you weekly reminders leading up to the outreach event with link to upload and submit**
I'm ready to do it now!
I don't have the documents ready so I will need to send these in later.
I have volunteered with Hope Smiles in the last year so you should have an updated copy.
23
Please upload a copy of your hygiene license**This document is required for you to volunteer with Hope Smiles so if you do not upload it now we will be sending you weekly reminders leading up to the outreach event with link to upload and submit**
Drag and drop files here
Select files to upload
Max. file size: 10.6MB
Cancelof
24
Dental Volunteers: We will need a copy of your malpractice insurance. This can be a photo of the document taken from your phone or a digital version, whichever is easier. Are you ready to upload this now or do you want to do it later?* This field is required.**This document is required for you to volunteer with Hope Smiles so if you do not upload it now we will be sending you weekly reminders leading up to the outreach event with link to upload and submit**
I'm ready to do it now!
I don't have the documents ready so I will need to complete this later.
I have volunteered with Hope Smiles in the last year so you should have an updated copy.
25
Please upload a copy of your malpractice insurance**This document is required for you to volunteer with Hope Smiles so if you do not upload it now we will be sending you weekly reminders leading up to the outreach event with link to upload and submit**
Drag and drop files here
Select files to upload
Max. file size: 10.6MB
Cancelof
26
Dental Volunteers: We will need a copy of your dental license. This can be a photo of the document taken from your phone or a digital version, whichever is easier. Are you ready to upload this now or do you want to do it later?* This field is required.**This document is required for you to volunteer with Hope Smiles so if you do not upload it now we will be sending you weekly reminders leading up to the outreach event with link to upload and submit**
I'm ready to do it now!
I don't have the documents ready so I will need to complete this later.
I have volunteered with Hope Smiles in the last year so you should have an updated copy.
27
Please upload a copy of your dental license**This document is required for you to volunteer with Hope Smiles so if you do not upload it now we will be sending you weekly reminders leading up to the outreach event with link to upload and submit**
Drag and drop files here
Select files to upload
Max. file size: 10.6MB
Cancelof
28
Please review:

Patient Information Privacy Policy

· Patient protected data may not be discussed or shared outside the office or event

· Patient information may not be discussed with other patients

· Patient Records must not be left unattended in public areas

· Patient Records may only be accessed for legitimate and assigned business needs

Violation of these policies can carry serious consequences for Hope Smiles. Anyone violating these policies may be terminated as a volunteer.
29
I have read and understand Hope Smile’s Patient Information Privacy Policy as stated previously. * This field is required.
Clear
30
Release and Indemnification Policy* This field is required.I hearby release and indemnify Hope Smiles, which is a non-profit organization, and all its respective officers, directors, agents, contractors, employees, heirs, successors and assigns from prosecution or presentation of any claim for bodily injury or death or for property loss or damage incurred in connections with Hope Smiles, expeditions or related activities. Intending to be legally bound, I have hereunto set my hand this (please select today's date below)
Date
Year
Month
Day
31
I have read and understand Hope Smile’s Release and Indemnification Policy as stated previously.* This field is required.
Clear
32
Photo Release Consent: As a member of the Hope Smiles team, you are awakening hearts and mobilizing a global community of leaders to restore hope and transform lives through dentistry. Part of this is telling the stories of restored hope and transformations to the world! As a Hope Smiles volunteer, pictures may be taken of you volunteering at events and used for Hope Smiles promotional materials. Do you consent to this?* This field is required.
YESNO
33
I have read and understand Hope Smile’s Photo Release Policy as stated previously and agree with use of my photos to help tell the Hope Smiles story.* This field is required.
Clear
34
Are you interested in receiving text messages with reminders about upcoming outreach details?* This field is required.We pinky promise we won't send you too many!
YESNO
35
Great! What is the best number to send these reminders to?
Area Code
Phone Number
36
Thank you for your interest in serving with Hope Smiles! We have your contact information and will be sure to let you know of any other upcoming outreaches. We hope you have a great day!
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