Volunteer Form

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
Are you a Licensed Medical Provider?

Section I-(check √) Volunteer Area of Interests (Please do not select more than two area of interest)

Area of Interest

Committee Name

Committee Function



Provide Medical Services and patient check-up

Medical Staff (RN/MA)


Clinic Administration, Medical Service

Clinic Administration


Clinic Administration

Section II-Volunteer Personal Data
First Name
Please Enter First name
Last Name
Please Enter last name
Date of Birth (MM/DD/YYYY)
Not a valid birthday format
Gender is required
Address is required
City is required
Zipcode is required
Not a valid email address
Cell Phone
Please Enter Phone Number
Alternate Phone

Section III-Work Experience
Current Occupation
Current Employer & Address
Section IV-Skills
Languages other than English
Special Skills

Section IV-Confidential Information
EHS requests the following information because of our dedication and commitment to the patients we serve. As a medical facility we must take reasonable precautions when giving medical care.

Have you ever been convicted of a crime? *
(i.e. felony or misdemeanor, but not including minor traffic violations or any conviction as a youthful offender.)

A conviction will not necessarily be a bar to your acceptance as a volunteer.
Have you ever been arrested or convicted for the use or sale of illicit drugs?*
Have you ever been arrested or convicted of child abuse or neglect?*

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