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)
Select

Area of Interest

Committee Name

Committee Function

Practitioners 

Medical

Provide Medical Services and patient check-up

Medical Staff (RN/MA)

Clinic

Clinic Administration, Medical Service

Clinic Administration

Clinic

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
Gender is required
Address
Address is required
City
City is required
Select all States
Select Atleast On State
Cell Phone
Please Enter Phone Number
ZipCode
Zipcode is required
Email
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
Degrees/Certifications
Special Skills

Section IV-Please provide two professional References

First Reference
Name
Please Enter name
Cell Phone
Please Enter Phone Number
Email
Not a valid email address
Select Relationship
Second Reference
Name
Please Enter Name
Cell Phone
Please Enter Phone Number
Email
Not a valid email address
Select Relationship


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