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- I am interested in volunteering at one or more of the following schools that is not yet scheduled.
- I am interested in applying fluoride at one or more of the following schools that is not yet scheduled.
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Format: (000) 000-0000.
- Are you over 18?*
- If the position I choose happens to be filled by another volunteer, I am still willing to attend and volunteer in other capacities.*
- I understand that any information (written, verbal, or other) obtained during the performance of my volunteer duties must remain confidential. This includes all information about members, patients, families, employees and other associate organizations, as well as any other information otherwise marked or known to be confidential. This includes all Protected Health Information defined by the Health Insurance Portability and Accountability Act (HIPAA) and any individually identifiable information, including student name, insurance status, treatment rendered, and all information pertaining to previous or existing health conditions or treatment needs, and any other information that may be used to identify an individual. I understand that any unauthorized release or carelessness in the handling of this confidential information is considered a breach of duty to maintain confidentiality. I further understand that any breach of the duty to maintain confidentiality could be grounds for immediate dismissal and/or possible liability in legal action arising from such breach.*
- MEDIA RELEASE: I hereby consent that any photographs/video/audio taken of me by Cass County Health Foundation may be used by them or assignees for the purpose of illustration, teaching, web content, or publicity in any form. NOTE: If you do not want to be photographed, please also remind the Cass County Dental Clinic employee who is present at each dental screening event.*
- By answering "Yes" below, I certify that I have completed this form accurately and on my own behalf.*
- Are you fluent in Spanish?*
- I am interested in helping prep for Dental Screenings by coming to the clinic for the following:
- I am interested in helping prep for 2026-2027 Dental Screenings by coming to the clinic for the following:
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- Should be Empty: