Volunteer Application

EIXSYS Healthcare System (EHS) is a community‐based non-profit tax-exempt charity organization as described in Section 501(c)(3) of the Internal Revenue Code; EIN 46-5413288, founded on being non-denominational and fostering a multi-cultural environment. Through volunteers EHS provides healthcare services; EIXSYS Healthcare System offers FREE preventative healthcare medical checkups\follow-ups to those that fall under 100% Federal Poverty Level. This project cannot run without the support of volunteers like you.

This application must be filled by all volunteers. All information will be kept confidential.

1 Basic Info
2 Personal Data
3 Experience
4 References
5 Agreement

Professional Information

Section I - Volunteer Area of Interests

Please do not select more than two areas of interest

Practitioners

Medical Committee

Provide Medical Services and patient check-up

Medical Staff (RN/MA)

Clinic Committee

Clinic Administration, Medical Service

Clinic Administration

Clinic Committee

Clinic Administration

Section II - Volunteer Personal Data

Please Enter First Name
Please Enter Last Name
Not a valid birthday format
Gender is required
Address is required
City is required
State is required
Zip code is required
Please Enter Phone Number
Not a valid email address

Section III - Work Experience

Section IV - Skills

Section V - Professional References

Please provide two professional references who can speak to your qualifications.

First Reference

Please Enter Name
Please select relationship
Please Enter Phone Number
Not a valid email address

Second Reference

Please Enter Name
Please select relationship
Please Enter Phone Number
Not a valid email address

There shall be no discrimination against an otherwise qualified individual on the basis of race, color, ethnicity, sex, religion, creed, national origin, age, disability, marital status, veteran status, or any other basis prohibited by federal, state, or local law