• Volunteer Sign-Up Form Philadelphia, PA 10/16/2026 - 10/18/2026

    Please provide your details and attach any relevant documents to register for the clinics. Sign-ups close 9/4/2026.
  • Format: (000) 000-0000.

  • SERVICE AREA

    Select interested service area(s) and shift(s). (Official schedule will be sent two weeks prior to clinic date)
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  • LIABILITY WAIVER

    I hereby release and indemnify DentMed, Inc a non-profit organization, and all its respective officers, directors, agents, contractors, employees, heirs, successors and assigns from any claim for bodily injury or death or for property loss or damage incurred in connection with DentMed, Inc its missions or related activities. I also release and indemnify DentMed for any claims against DentMed by others as a result of my actions or inactions while volunteering for DentMed, Inc, whether those actions are intentional or in negligence, and whether civil or criminal in nature. I fully understand that I am volunteering at my own risk regardless of the environment or services I am voluntarily performing for DentMed, Inc. Additionally, but without limitation, I specifically release and indemnify DentMed, Inc. in relation to:

    1. Any volunteer service I engage in which exposes me to blood or other potentially infectious materials putting me at risk of acquiring Hepatitis B virus (HBV) infection or other blood borne pathogens. I understand that if I do not have the HBV vaccine, I continue to be at risk of acquiring Hepatitis B, a serious disease. If, in the future, I want to be vaccinated with Hepatitis B vaccine, I can acquire the vaccination at my own expense; and,

    2. The working environment at the DentMed, Inc. location where I volunteer which may take place near or involve working with or on heavy equipment and/or machinery, livestock, toxic materials, dangerous, and other potentially high risk activities.

    3. I further hereby grant to DentMed, Inc and its employees, directors, officers, agents, providers, and sponsors the right to use my picture, voice, or other reproductions of my physical likeness in connection with any advertising, publicizing or activities by DentMed, Inc. or any of its sponsors or Providers, in all media form, in perpetuity.

  • VOLUNTEER WAIVER AGREEMENT

    By completing this application on behalf of myself, my personal representatives, heir, assigns and anyone else entitled to claim through me, I do hereby waive any right of recover, and release DentMed, Inc their officers, trustees, officials, employees and agents, and other volunteers from liability related to , arising from any and all injury to persons and damage to property, and further agree to undertake to indemnify, hold harmless and defend the DentMed, Inc from and against any and all claims, damages, actions, liability and expenses including attorney’s fees and other professional fees in connection with bodily injury including death, personal injury and/or other damage to property arising from or out of the volunteer activities and participating in volunteer service at the DentMed, Inc Pop-up Clinic

    I further acknowledge and agree that DentMed, Inc do not assume any responsibility whatsoever for any property of the volunteer, and the volunteer shall not hold them liable for any loss or damage to same.

    In compliance with the HIPAA Privacy Act: I further agree to hold in confidence all personal and protected health information I may see, read, overhear, have access to, or come in contact with during and following the DentMed, Inc Pop-up Clinic.

    I also grant DentMed, Inc and their agents the right to use, without payment or consideration of any kind, my picture, voice and other reproductions of my physical likeness in connection with advertising or publicizing DentMed, Inc services and their activities in all forms of media in perpetuity.

    All clinical providers rendering oral health, medical and vision services must have all appropriate and active licenses issued by the appropriate licensing authority to provide treatment to DentMed, Inc patients and must have a current Hepatitis B vaccination. Your acceptance of the DentMed, Inc Volunteer Service Agreement signifies that you give permission to DentMed, Inc to verify the status of your license.

    The above waiver extends to any related claims which may arise after the DentMed, Inc clinic is completed.

    I have read and accept the terms and conditions stated above.

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