NCDHM 2025 IOH + Colgate BSBF Volunteer Opportunities

Thank you for your interest in being a volunteer aboard the Colgate BSBF Mobile Van Unit! Please select the state in which you are interested in volunteering. Once your state is selected you will see dates, cities and times of available sites where volunteers are needed. From there, please select the site and shift that you wish to volunteer for, provide your contact information and complete the necessary waiver & consent forms. Further information from Colgate, BSBF will be provided within 2 business days of the completion of this survey. *Please note that you must complete the form in its entirety to receive your confirmation details and shifts are subject to change, but any changes will be communicated to volunteers, in advance.

Select which CA event you wish to volunteer for:

Select which DC event you wish to volunteer for:

Select which FL event you wish to volunteer for:

Select which GA event you wish to volunteer for:

Select which IL event you wish to volunteer for:

Select which NJ event you wish to volunteer for:

Select which NY event you wish to volunteer for:

Select which TX event you wish to volunteer for:

2. Provide your contact information and additional information below: *This question is required.

First Name *This question is required.

Last Name *This question is required.

Email Address *This question is required. This question requires a valid email address.

Primary Phone *This question is required.

Are you bilingual? (Enter Yes/No) *This question is required.

3. If yes above, what other language/languages besides English?

4. Please check one: *This question is required.

5. License # (if applicable):

6. I am licensed to practice in the following state/states (if licensed):

7. Expected or former month/year of graduation: *This question is required.

8. Name of employer or college/university affiliation *This question is required.

9. PHOTO CONSENT AND RELEASE
For good and valuable consideration, the receipt and sufficiency of which is hereby acknowledged, I hereby grant to Colgate-Palmolive Company, American Dental Hygienists Association and the Institute for Oral Health Foundation, its subsidiaries, affiliates, agents, successors, legal representatives, assigns and those acting for or on its behalf including, without limitation, its advertising and publicity agencies (all hereinafter referred to collectively as “Company”), the perpetual, irrevocable right and permission to use, at any time and from time to time, my name, any pseudonym, my signature, my biographic data, my voice, my photograph(s) or likeness, or any part thereof, in any form (including caricature), and any statements made by me either alone or accompanied by other material (all of the foregoing elements are referred to collectively as my “Identity”), in any manner, throughout the world, for advertising, promotion, publicity, trade or any other lawful purpose, in any medium now known or hereafter developed including, without limitation, printed media, digital and electronic media, audiovisual recordings, still photographs and the Internet.

I represent and warrant that I have the right to use, and allow Company to use, any photograph(s) provided by me to Company for these purposes, and that my biographical information that I provided is accurate.

On behalf of myself I hereby release and discharge Company from any claim or liability (including, without limitation, copyright infringement, defamation, false light, invasion of privacy or right of publicity) based upon any use of my Identity or any element thereof for such purposes, including alteration, blurring, distortion, optical illusion, retouching or use in a composite form of my/my child’s photograph or likeness or any part thereof, whether or not intentional.

Furthermore, I agree that my electronic signature is the legal equivalent of my manual/handwritten signature on this document and by marking "Yes", I consent to the legally binding terms and conditions as set forth above. *This question is required.

10. Electronically Signed (Enter full legal name): *This question is required.

11. Date of Signing: *This question is required. This question requires a valid date format of MM/DD/YYYY.

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12. FOR LICENSED HYGIENISTS OR DENTISTS ONLY: I certify that my license is in good standing and will be in good standing at the time and date of the event that I am scheduled for.

13. Electronically Signed (LICENSED HYGIENISTS OR DENTISTS ONLY):

14. Date of Signing (LICENSED HYGIENISTS OR DENTISTS ONLY): This question requires a valid date format of MM/DD/YYYY.

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15. Volunteer Registration Form
This document is editable, please type in your information, save it to your computer then upload it by clicking on the "Browse" button below. If you are unable to upload the edited document, please submit your volunteer request without an updated form and email the updated form directly to institute@adha.net. If you do not submit your Alchemer volunteer shift request, you will not be registered for a shift or receive any confirmation information.

Volunteer Registration Form_PDF *This question is required.

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