VOLUNTEER REGISTRATION
Albuquerque NM MOM - October 14-17, 2010
(You are strongly urged to submit your NM MOM Volunteer Registration form by October 1, 2010) [Two weeks prior to event]
Last Name:
First Name:
Degree/Certification:
Professional License Number:
Address:
City:
State:
Zip Code:
Cell Phone:
Alternate Phone Number:
Email (VERY IMPORTANT):
Aside from English, please indicate language you speak fluently:
Not applicableSpanish
Other language(s) 		Are you 18 or older?
YesNo
How old are you?		What size of NM MOM T-shirt?
          SML
          XLXXLXXXL
Please indicate volunteer type, and work preference if indicated:
DENTAL TEAM
I have had a hepatitus vaccination
Dentist: Name of preferred dental assistant:
Indicate work preference
TriageAnesthesiaRestorativeEndodonticsPeriodontics
ProsthodonticsOral SurgeryPediatricsWherever needed
Retired dentistDental assistantDental lab technician (denture preparation/repair)
Dental studentDental assistant studentDental equipment maintenance person
Predental studentDental x-ray technicianDental hygenist
Dental billing coderDental hygiene student 
NONDENTAL HEALTH PROFESSION TEAM
I have had a hepatitis vaccination   
MDRNPharmacistEMT
Student RNPharmacist Tech  
COMMUNITY WORKERS (please indicate work preference)
TranslatorChild CareRunner
Patient registrationCrowd controlSecurity
Patient escortEntertainmentTraffic/parking monitoring
Patient exit interviewsEquipment set-up/tear-downVolunteer registration
Data entry (Microsoft Excel expertise)Food ServiceWaste management
Wherever needed  
Please indicate days you would like to volunteer, and if you will be attending a volunteer dinner:
Thursday, October 14th - 7:00am-5:00pm: Clinic set-up (dental units, supplies, tables, chairs, signs, etc.)
     I will attend the volunteer dinner
Friday, October 15th - 5:00am-5:00pm: Dental clinic
     I will attend the volunteer dinner
Saturday, October 16th - 7:00am-5:00pm: Dental clinic
     I will attend the volunteer dinner
Sunday, October 17th - 8:00am-2:00pm: Clinic take-down