2024 Minnesota Mission of Mercy
Welcome to the registration site for the 9th Minnesota Mission of Mercy at the Duluth Entertainment Convention Center
Volunteer Information
* = Required
*
First Name
*
Last Name
Company
Title/Degree
*
Address 1
Address 2
*
City
*
State
Choose...
Other
AB
AK
AL
AR
AZ
BC
CA
CO
CT
DC
DE
FL
GA
HI
IA
ID
IL
IN
KS
KY
LA
MA
MB
MD
ME
MI
MN
MO
MS
MT
NB
NC
ND
NE
NH
NJ
NL
NM
NS
NT
NU
NV
NY
OH
OK
ON
OR
PA
PE
PR
QC
RI
SC
SD
SK
TN
TX
UT
VA
VT
WA
WI
WV
WY
YT
Enter Other:
*
Zip
*
Registrant's E-mail Address
*
Confirm Registrant's E-mail Address
*
Cell Phone Number
*
Day Time Phone Number
Registration Information
* = Required
*
Will you be at least 18 years old on
June 6, 2024?
Yes
No
*
Volunteer Waiver
Click here
All volunteers must read this waiver and indicate by checking the box.
Yes, I have reviewed and accepted the waiver
*
Have you volunteered at a previous MN Mission of Mercy?
YES
NO
*
What years did you volunteer?
2012-Mankato
2013-Bemidji
2014-Mankato
2015-Duluth
2016-Moorhead
2018-Minneapolis
2022-St.Cloud
*
Do you speak a second language?
Yes
No
*
Would you be willing to help
translate if needed?
Yes
No
*
Language:
Select...
American Sign Language
German
Hmong
Somali
Spanish
Other
*
Name Prefix
Select...
Dr.
Ms.
Mr.
Mrs.
Miss
Sr.
Rep.
Sen.
Comm.
MnMOM requires that all volunteers be at least 18 years of age. Certain exceptions will be made for high school students working to complete volunteer requirements, however, prior arrangements must be made. Please contact Vicki, mnmom@mndental.org
*
PLEASE CHOOSE A VOLUNTEER TYPE:
Select...
ADCF staff
Delta Dental Employee
Dental Assistant
Dental supply company representative
Dental therapist (licensed)
Endodontist
General dentist
General Volunteer
Guest/Observer
Hygienist (registered)
Lab technician
MDA Staff
Medical Assistant
MnMOM Chair/Lead
Nurse (any license)
Oral surgeon
Orthodontist
Pediatric dentist
Periodontist
Pharmacist
Pharmacy technician
Physician
Physician's assistant
Prosthodontist
Radiologic Technologist (Registered)
Student - dental assisting
Student - dental school
Student - dental therapist
Student - hygiene
Student - Medical/Nursing
Student - pharmacy
Student - physician's assistant
Translator
UofM Dental Faculty
*
Do you currently hold an active,
unrestricted license to practice in Minnesota?
Yes
No
DOWNLOAD
a volunteer license application (submit to MN Board of Dentistry). This must be submitted by June 1, 2024.
MN Board of Dentistry requires that you bring your 3.5'x 4.5' small license to the event. MOM will require all dental professionals treating patients to display their renewal certificate or guest license. (Volunteer registration will provide a badge holder to display your license)
*
Dental Student Year
D2
D3
D4
Please contact
Janelle Jehn
regarding CMA for MnMOM event.
*
T-shirt size
Select...
X-Small
Small
Medium
Large
X-Large
2XL
3XL
4XL
5XL
*
Scrub Top size
Select...
No Shirt Post-op DDS
X-Small
Small
Medium
Large
X-Large
2XL
3XL
4XL
5XL
*
Lead Shirt
Select...
X-Small
Small
Medium
Large
X-Large
2XL
3XL
*
Number of Shirts
Select...
1 shirt needed (working one day)
2 shirts needed (working two days)
No Shirt Post-op DDS
Event Location
Duluth Entertainment Convention Center
350 Harbor Drive
Duluth, MN 55802
United States
Parking & Directions
Contact
Vicki Capistrant
Program Coordinator
MnMOM@mndental.org
Social Networking
Forms
Volunteer Waiver and Release Form.pdf
2024 MN Bd of Dentistry Volunteer-Guest Application.pdf
