Friends of Creston Children's Dental Clinic Volunteer Application
Thank you for your interest in Friends of Creston Children’s Dental Clinic! We provide a dental home for uninsured and low-income children in Portland Public School District. Volunteer providers like you keep our patients pain-free and smiling.

Please complete this application to begin as a volunteer at FCCDC. Before your first volunteer shift, you will also need to complete a background check form and provide us with a copy of your license.

The Friends of Creston Children's Dental Clinic
Contact information
Name *
Your answer
Address *
Your answer
City *
Your answer
ZIP code *
Your answer
Email address *
Your answer
Primary phone number *
Your answer
Primary phone type *
Secondary phone number
Your answer
Secondary phone type
Birthday *
Month and date
Your answer
Licensure and availability
Licensure *
Are you volunteering in order to fulfill a requirement?
What days are you available to volunteer? *
As of April 2016, our clinic hours are Tuesday through Friday, 8:30am to 3:30pm, with lunch from 12-12:40.
Required
How often are you interested in volunteering? *
Required
Are you interested in being on our list of volunteers to call to fill unexpected vacancies? *
We will always give you at least one day's notice, and you are of course always able to refuse a shift.
Are there any procedures you are NOT willing to perform? Our patients are 5 to 18 years old, and we do not have nitrous oxide or sedation available.
Please list; i.e. extractions: 3rd molar, primary, perm simple, surgical; endo/RCT: ant, bi-cuspid, molar, start endo, finish endo; unwilling to work with a particular age group; primary teeth only, etc.
Your answer
Do you have specific experience or specialties that you would like to offer the clinic?
Your answer
Dentists and hygienists, please list your malpractice insurance company.
The clinic carries malpractice insurance as well.
Your answer
Are you vaccinated against hepatitis B? *
Next
Never submit passwords through Google Forms.
This content is neither created nor endorsed by Google. Report Abuse - Terms of Service