TDHA Forms
If you are volunteering, please download the volunteer form, fill it out, and send it to Rita Snodell so our component can be recognized by the state association for our volunteer efforts.
The Texas Dental Hygienists’ Association
Download Form: Microsoft Word or Adobe PDF
FORM #1
Volunteer dental hygienists and dental hygiene students provide preventive dental services for children and adults. Services may include the following: oral hygiene instruction, screening orassessment, sealants, topical fluoride and fluoride varnish applications*. Oral health education may include meeting the Tooth Fairy and learning about oral health. Want to know what tobacco does to your mouth? Come take a look…for a guided tour of your mouth and education about smoking & dip (snuff) cessation. These & other preventive services are available from your dental hygienist.
Event Sponsor/Title:_______________________________________________________
Event Location:___________________________________________________________
Event Date: _______________________________ Time:___________________________
I CAN VOLUNTEER FROM ____ AM – 12 noon _____ 12 noon –PM
[Bring form/gloves/protective lenses]
Event Contact Person: _________________Phone/email: ___________________
Your Name __________________ Phone ___________________________
Address__________________________________City__________ Zip _________
E-mail address: ________________________________________________________ Bilingual? YES___ NO___
Liability Coverage: YES___ NO___ Company: _______________________________________________________
For Students Only: DentalHygieneSchool: ___________________________________________________________
Instructor tracking your community service record: ______________________________________________
Previous Fluoride Varnish experience: Yes___ No___This is simple to do. We can help you.
*Please review the online video, as it will help your proficiency with varnish application technique with young children. Practice this simple & manageable procedure by spreading a thin layer of toothpaste with swab over a smooth surface.
http://meded1.ahc.umn.edu/fluoridevarnish/xindex.htm :
<take the course> <course contents>This takes only a few minutes. <module 6> video is 2 minutes long
TDHA and/ or the Sponsor named above may use my photograph for publicity including but not limited to newspaper, TV, radio, website, newsletters & display boards.
Signature Date
Please mail or e-mail this registration to:
Texas Dental Hygienists' Association
Public Affairs Council Chair- Lynn Durham
1011 Timber Creek Dr.
Lewisville, TX 75067
972-436-2335 home
72-754-0498 cell
4durham@gte.net_________________________________________________________ _ |
