• CTMOM 2011 Volunteer Registration Form

  • CTMOM Registration is Closed!

    Thank you for your interest in volunteering for the 2011 CTMOM. Registration is Closed!

    All Saturday volunteer opportunities are currently full.  Please consider volunteering for another day. Thank You. 

    Please note: In order to provide treatment services to CTMOM patients, all clinical providers  must have all appropriate/relevant  active licenses issued by the state's appropriate licensing authority. In addition, all clinical providers must have current malpractice insurance.

    Out of state clinicians must bring a copy of their state license and medical malpractice insurance.   

    Please note the following information: 

    1.  All volunteers must be at least 16 years old to volunteer on actual clinic (treatment) days.  Volunteers under the age of 16 will only be allowed to volunteer on set up and breakdown down days. 

    2.  Please be aware this is the weekend of  Palm Sunday.  Although it is a holiday, we hope you will consider volunteering for the clinic as we would like to treat as many patients as possible.  

    3.  Please be sure to spell your name correctly and capitalize the first  letter of your first and last name  as this is the way it will appear on your badge.

     

    By submitting this form, you grant the Connecticut Foundation for Dental Outreach and its agents the right to use your picture, voice and other reproductions of your physical likeness in connection with advertising or publicizing Mission of Mercy services and its activities in all forms of media in perpetuity, as outlined in the Volunteer Services Agreement.

  • Contact Information

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  • Demographics

  • I have a Current hepatitis vaccination*
  • T-Shirt size*
  • Do you speak another language well enough to interpret?
  • If you were a previous CTMOM volunteer, please check year(s) that apply

  • Dental/Medical Volunteers

  • Check all which apply:

  • Please select your work preference

  • If you are a dental student:

  • Year

  • Community Volunteer

  • Please select your work preference

  • Availability

  • In general, most CTMOM positions will follow the schedule below. Some areas will need to come in earlier/later. Your team lead will contact you with more details and start time  as the event approaches.  All volunteers must attend an orientation session to be held 1/2 hour before your shift begins. 

    Please note that we will do our best to honor your full request; in some cases we may have filled your preferred position in your available time slot and will place you in another area appropriate to your talents.

  • Please check off which day/days you would like to volunteer NOTE: Thurs. Fri. Mon, No patient treatment hours*

  • Emergency Contact Information

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  • By submitting this volunteer application, you are committing to volunteer on the dates you have selected. If you are unexpectedly unable to fulfill your obligation please email jbicknell@csda.com

    We are counting on you!


    CTMOM 2011 - It won't happen without you.

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