For the Love of God Dentistry
Free Dental Day Saturday, June 3, 2023
Hosted by: Greece Family Dentistry and Implantology
3101 West Ridge Road
Building C
Rochester, NY 14626

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Volunteer Registration and Release Form
How did you hear about the Free Dental Day event? Who may we thank for asking you to participate?
Have you volunteered with us at a previous "Dentistry from the Heart" Free Dental Day Event? *
Name
Address
Home Phone Number
Cell Phone Number
Email Address (please check email for more details to follow) *
Within which department are you prepared to serve? *
For medical professionals only, NYS license number:
Which shift are you available? (please check all that apply) *
Required
Additional comments regarding availability:
T-Shirt Size (We have a limited number of TShirts available on a first come first served basis. Please indicate desired unisex size) *
As a volunteer at the above designated For the Love of God Dentistry Event, I agree to follow the directions of designated practice managers in my efforts offered in support of this free dentistry public service.  Furthermore, I agree to hold the above practice, its officers, and the For the Love of God Dentistry organization blameless for any injuries or other difficulties encountered in the execution of my duties.   This volunteer releases For the Love of God Dentistry, a nonprofit organization, the above dental practice, and all associated officers of said organizations from liability pertaining to the free dentistry event to be undertaken. I consent and provide permission for use of images and videos to be used for publication, advertising, and marketing efforts with no claim for compensation or liability. These files shall remain the property of For the Love of God Dentistry & Greece Family Dentistry and Implantology. No activities are to be undertaken without the express permission of said practice and without proper license for technical undertakings pertaining to treatment offered. This Release and Waiver of Liability executed by myself (Name of Volunteer) *
Digital Signature *
Today's date: *
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Thank you so much for your support! We will be in contact with additional information and ways for you to help spread the word!
IRS 501 (C) (3) For the Love of God Dentistry –
Public Charity Status Per: 170 (b) (1) (A) (VI)
Taxpayer Identification Number: 86-2790416 For the Love of God Dentistry
If you have any questions, please contact our Event Coordinator
Christa Cabrera
FortheLoveofGodDentistry@gmail.com
(585) 487-8618
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