We Make a Difference

Our Participants Are All Smiles!!!

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join the cause to spread smiles across the world

Please use this signup form to register. If Applicable; By submitting this form you hereby attest that your professional license is not restricted, suspended or revoked, nor is any such action pending, pursuant to disciplinary proceedings in any jurisdiction.
    I am volunteering on June 27th from 8:00am – 5:00pm at the Powhatan Fair Grounds 4042 Anderson Highway, Powhatan, VA 23139 as a:
    I hereby grant permission to Saving Smiles Dental Clinic representatives to take and use: photographs, quotes, testimonials, and/or digital images of me for use in news releases and/or education materials. These materials might include printed or electronic publications, websites or other electronic communications. I further agree that my name and identity may be revealed in descriptive text or commentary in connection with the image(s) or statement(s). I authorize the use of these images or statements without compensation to me. All negatives, prints, digital reproductions shall be the property of the Powhatan Dental Outreach Foundation For Children.

 

Exposure Control Plan

I understand there is potential risk for exposure to blood borne pathogens (BBPs) including human immunodeficiency virus (HIV), hepatitis B virus (HBV), and hepatitis C virus (HCV), as well as other bacteria, protozoa, viruses and prions during the performance of my volunteer service at this Saving Smiles Dental Clinic Event. I understand that I am personally responsible for any medical fees and services associated with a percutaneous piercing wound typically set by a needle point, but possibly by other sharp instruments or objects.

By completing this volunteer registration, I acknowledge that I have read, understand, and agree to adhere to the exposure control plan.

Confidentiality Policy

I understand that while I am participating as a registered volunteer for a Saving Smiles Dental Clinic event, it is mandatory that I maintain complete privacy and confidentiality of all patients. This pertains to all present and future digital, written and verbal communications referring to any Saving Smiles Dental Clinic Patient. I also understand that unless I am obtaining information strictly for patient registration, I DO NOT ASK a patient any questions regarding medical/dental insurance coverage or Medicaid/FAMIS.

By completing this volunteer registration, I acknowledge that I have read, understand, and agree to adhere to this policy of confidentiality for Saving Smiles Dental Clinics.

Release and Indemnification

Upon completion of this registration, I release and indemnify Saving Smiles Dental Clinic, a non-profit outreach program of the Powhatan Dental Outreach Foundation For Children, All their respective officers, directors, agents, contractors, sponsors, heirs, successors and assigns, from prosecution or presentation of any claim for bodily injury or death or for property loss or damage incurred in connection with the Saving Smiles Dental Clinic event or related activities.