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

Section I-(check √) Volunteer Area of Interests (Please do not select more than two areas 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
Please Enter First Name
Please Enter Last Name
Not a valid birthday format
Gender is required
Address is required
City is required
Select At least One State
Please Enter Phone Number
Zipcode is required
Not a valid email address

Section III-Work Experience

Section IV-Skills

Section IV-Please provide two professional References
First Reference
Please Enter Name
Please Enter Phone Number
Not a valid email address
Second Reference
Please Enter Name
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