MOMOM Registration

2022 MOMOM Volunteer Registration

It’s Been a Minute, Please Read 2022 Changes Carefully

  • Your service is greatly appreciated and will make a big difference in the lives of many.
  • We are planning for a prescreening with a select patient audience from 3-5pm on Thursday, July 14 and will need more personnel for this shift than in previous years.
  • The actual treatment clinic will be Friday, July 15 and Saturday, July 16. All treatment/volunteer services will take place at Chaifetz Arena, 1 S Compton Ave, St. Louis MO 63103. 
  • We have two, 5-hour clinic shifts to choose from each day: 7a–Noon and Noon–5p. We ask that volunteers show up an hour prior to their shift (6a/11a) to manage parking, check in, final instructions, etc.
  • Our intention is to keep the treatment chairs full all day.
  • Notice that some volunteer roles are primarily morning shift only.
  • Review Volunteer Descriptions and Volunteer FAQ if necessary, before registering. 

Please Read the Following Instructions!

Each individual desiring to volunteer for MOMOM MUST follow these instructions:

  • We MUST receive a separate registration for EACH volunteer every year.
  • Any fields marked with an asterisk (*) are required before submission.
  • When you complete this form, you MUST check the box at the end, which indicates you have READ and AGREE TO the Liability and Service Agreement Waiver Guidelines. You cannot submit your registration without doing so.
  • Once you have completed the form correctly, you will receive a confirmation page and a confirmation email. Please check your SPAM folder if you have not received a confirmation email in a short amount of time after registering.

Contact Information


Volunteer Selection

From the following 8 categories, choose ONE CATEGORY that best describes you, then SELECT ONE ROLE in that drop down menu. (review Volunteer Descriptions if necessary). Final assignments will be made two weeks prior to MOMOM. We make every effort to honor your preference, but on-site adjustments may occur to maximize clinic efficiency.


Shift Selection (Note NEW Shift Times)

Some volunteer roles may have slightly different shift times. Your lead will inform you via email of any variances to the normal shift schedule. Some positions will have optional Zoom orientation prior to the clinic. Times TBD. 

"What can I expect during the various shift times available?" 
See the Volunteer FAQ for an answer to this and other volunteer questions. 

Thursday, July 14: Set-Up Day
Morning Shift:
8a–Noon (morning truck unload, basic set up)
Afternoon Shift: Noon–5p (continued set up, fine tuning)
Pre-Screen Shift: 3–5p (patient registration, medical/dental triage, x-ray)
Thursday Shifts (check all that apply)



Friday, July 15: Clinic Day One
Morning Shift:
7a–Noon (arrive 6a)
Afternoon Shift: Noon–5p (arrive 11a)

Friday Shifts (check all that apply)


Saturday July 16: Clinic Day Two
Morning Shift:
7a–Noon (arrive 6a)
Afternoon Shift: Noon–5p (arrive 11a)
Teardown Shift: 3p–Done (pizza provided)

Saturday Shifts (check all that apply)



Liability Guidelines

Before you can submit your registration, all volunteers MUST READ and CHECK THE BOX indicating they have read, in full, all information below including that which is SPECIFIC to their volunteer type.

COVID-19 Assumption of Risk & Waiver of Liability

The novel coronavirus, COVID-19, has been declared a worldwide pandemic by the World Health Organization. COVID-19 is extremely contagious and is believed to spread mainly from person-to-person contact. As a result, federal, state, and local governments, and federal and state health agencies recommend social distancing and have, in many locations, instituted their own requirements and guidelines. Governmental restrictions and the restrictions outlined below may change at any time without prior notice.

Missouri Mission of Mercy (MOMOM) event for 2022 has instituted the following policy for all attendees.

Guests must provide one of the following upon entry:

  • An official, government-issued vaccination card (physical or mobile image accepted) listing the person's name and date the last dose was administered along with a matching photo ID. *If children between the ages of 12-17 do not have a photo ID, a parent or guardian will be required to verify their identity.
  • A printed or digital negative COVID-19 PCR or rapid antigen test administered on site by a healthcare professional or pharmacy provider that includes the person's name along with a matching photo ID. Self-administered tests will not be accepted. 
  • Children under the age of 12 are exempt from this policy but they must be accompanied by a parent or guardian who meets the vaccination or negative test requirement.

In addition to these new protocols, all attendees over the age of 2 at the MOMOM event must continue wearing their face masks while indoors. A face mask may be removed for a brief period of time to eat or take a drink of a beverage, but when finished, attendees are expected to return their face mask to cover their nose and mouth.

MOMOM organizers cannot guarantee eligibility to travel to or to participate in the 2022 MOMOM event on July 14-16, 2022. Additionally, if MOMOM attendees choose to attend the MOMOM event and enter onto the Chaifetz Arena premises, they may be exposing themselves to and/or increasing their risk of contracting or spreading COVID-19.

MOMOM, the Missouri Dental Association, Missouri Dental Association Foundation, Chaifetz Arena, St. Louis University, Spectrum Venue Management, and the officers, directors, members, managers, agents, instructors, contractors, servants, employees and any other representation of the foregoing (collectively, the “Entities”) will seek to implement preventative measures to reduce the spread of COVID-19 consistent with the guidance and recommendations of public health agencies for slowing the transmission and exposure to COVID-19 which may include, but not be limited to, health questionnaires for all event participants, sanitation procedures, and physical distancing measures at Chaifetz Arena and during the MOMOM event.

By checking the “I Agree” box while registering, I, as a volunteer, acknowledge the contagious nature of COVID-19 and voluntarily assume the risk that I may be exposed to or infected by COVID-19 by accessing the MOMOM event in-person and that such exposure or infection may result in personal injury, illness, permanent disability, and death. As such, I, as a volunteer, accept the terms of this Assumption of the Risk and Waiver of Liability.

Registrant understands that the risk of becoming exposed to or infected by COVID-19 may result from the actions, omissions, or negligence of myself and others, including, but not limited to the Entities and other MOMOM event participants.

Registrant agrees to abide by all preventative measures outlined above (collectively “Measures”) put in place by the Entities at any time prior to and during the event including, but not limited to, wearing cloth face coverings at all times in public spaces, remaining at least six feet away from other event participants, and promptly notifying Missouri Dental Association Foundation if any registrant experiences symptoms of COVID-19 during the event. Registrant further agrees that any of the Measures may be modified or eliminated prior to the event at the discretion of the Entities and without advance notice to Registrant.

Registrant acknowledges that personal failure to follow these Measures may result in being removed from the MOMOM event and all related activities without any refund or reimbursement. Finally, Registrant acknowledges that no promises, representations, or affirmations of fact were made to me concerning the safety or danger associated with traveling to the event or participating in any activity or interaction related to or associated with the event.

MOMOM Volunteer Service Agreement—Waiver of Liability (Healthcare)

FOR HEALTHCARE VOLUNTEERS, By checking the ‘I Agree’ checkbox below, I, on behalf of myself, my heirs, executors, administrators, and assigns, in consideration of being allowed to participate as a volunteer in the Missouri Mission of Mercy (MOMOM) Event, waive any right of recovery and release the Missouri Dental Association (MDA), the Missouri Dental Association Foundation (MDAF), MOMOM, Chaifetz Arena, St. Louis University, Spectrum Venue Management, and the present and former officers, directors, members, managers, agents, instructors, contractors, servants, employees, volunteers and any successors, assigns and other representative of each of the foregoing (collectively, the “Releasees”) from liability, arising from any and all injury to persons and damage to property, including, but not limited to those which arise out of the NEGLIGENCE of any of the Releasees, and further agree and undertake to indemnify, hold harmless and defend the Releasees from and against any and all claims, damages, actions, liability and expenses including attorney’s fees and other professional fees in connection with bodily injury including death, personal injury and/or damage to property arising from or out of my activities and participation in volunteer services at the MOMOM event.

I, as a volunteer, further acknowledge and agree that none of the Releasees assume any responsibility whatsoever for my property and I shall not hold any of the Releasees liable for any loss or damage to same.

I, as a volunteer, further acknowledge and grant to the MDA and MDAF and their agents the right to use my picture, voice and other reproductions of my physical likeness in connection with advertising or publicizing MOMOM services and its activities in all forms of media in perpetuity.

I, as a volunteer, further acknowledge that I hold an active or volunteer Missouri license (or a license or registration in another state which permits me to practice in the State of Missouri) to practice in the category of professional service for which I volunteered for the MOMOM event as a dentist, oral surgeon, dental hygienist, expanded function dental assistant, physician, physician’s assistant, LPN, RN, nurse’s aide, EMT, pharmacist, or pharmacy tech or any other healthcare position.

I state and affirm that my license has not been revoked suspended or subject to probation and that I am not currently restricted from practicing the profession for which I have volunteered for the MOMOM event in any way in Missouri or in any other state in which I am licensed or registered. I also hereby state and affirm that I am not aware of any current or pending investigation relating to my license or registration to practice in Missouri or any other state in which I am licensed or registered.

I further represent and warrant to MDA and MDAF that neither I nor any entity in which I am an owner, officer, director, member, manager, or employee is excluded from participation in any federal health care programs, as defined under 42 U.S.C. Section 1320a-7b(f), or any form of state Medicaid program, and to my knowledge, there are no pending or threatened governmental investigations that may lead to such exclusion. I agree to notify MDA and MDAF of the commencement of any such exclusion or investigation within seven (7) business days of my first learning of it.

MOMOM Volunteer Service Agreement—Waiver of Liability (General)

FOR GENERAL COMMUNITY VOLUNTEERS, By checking the ‘I Agree’ checkbox below, I, on behalf of myself, my heirs, executors, administrators, and assigns, in consideration of being allowed to participate as a volunteer in the Missouri Mission of Mercy (MOMOM) Event, waive any right of recovery and release the Missouri Dental Association (MDA), the Missouri Dental Association Foundation (MDAF), MOMOM, Chaifetz Arena, St. Louis University, Spectrum Venue Management, and the present and former officers, directors, members, managers, agents, instructors, contractors, servants, employees, volunteers and any successors, assigns, and other representative of each of the foregoing (collectively, the “Releasees”) from liability, arising from any and all injury to persons and damage to property, including, but not limited to those which arise out of the NEGLIGENCE of any of the Releasees, and further agree and undertake to indemnify, hold harmless and defend the Releasees from and against any and all claims, damages, actions, liability and expenses including attorney’s fees and other professional fees in connection with bodily injury including death, personal injury and/or damage to property arising from or out of my activities and participation in volunteer services at the MOMOM event.

By checking the ‘I Agree’ checkbox below, I also grant to the MDA and MDAF and their agents the right to use my picture, voice, and other reproductions of my physical likeness in connection with advertising or publicizing the MOMOM services and its activities in all forms of media in perpetuity. Attorney’s fees and other professional fees in connection with bodily injury including death, personal injury and/or damage to property arising from or out of my activities and participation in volunteer services at the MOMOM.

By checking the below box, I certify that I have READ and AGREE to the COVID-19 Assumption of Risk and Waiver of Liability and the MOMOM Service Agreement–Waiver of Liability for both healthcare providers and general volunteers.
Liability Waiver Concent


Questions or Requested Changes

If you have questions about the event refer to the MOMOM web page or the Volunteer FAQ. If after you register, you need to make changes to your volunteer shift or have other changes, DO NOT re-register! Contact the MDA and we will process requested changes or cancellations: 573-634-3436 or mom@modental.org.

Before You Click Submit

All Dentists: MUST provide proof of malpractice coverage before providing care at MOMOM.
Out-of-State Dentists/Hygienists
MUST complete a Request to Provide Temporary Gratuitous Services Form
For both requirements: The Registration Confirmation page provides instructions.

Please allow the form time to submit! DO NOT re-click the submit button or refresh your browser during this time, as it could result in form processing errors. You know your form has submitted correctly when you are redirected to the Thank You/Confirmation page.

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