Become a Lima Memorial Volunteer

Website > Community Relations > Volunteering at Lima Memorial > Become a Lima Memorial Volunteer

Become a Lima Memorial Volunteer Become a Lima Memorial Volunteen

Become a Lima Memorial Volunteer

Volunteer & Auxiliary Member Application

Lima Memorial relies on more than 300 auxiliary volunteers to provide services to various departments and programs. They provide assistance to patients, families, visitors and staff. If you have questions about being a volunteer, please call the Volunteer Office at 419-226-5094.</br> </br>Please fill out the fields below to apply to become a Lima Memorial Volunteer and Auxiliary Member.

Last Name *

First Name *

Middle Name

Phone *

Email Address

Date *

Street Address *

City *

State *

Zip Code *

Date of Birth *

Spouse's Name

In case of an emergency, who should we notify? *

Relationship *

Emergency Contact Address *

Emergency Contact Phone *

Are you employed? *

Yes

If so, where are you employed?

Business Phone

Please list three references (only one may be family)

References

Please list three references below. Only one may be a family member.

Reference 1 Name *

Reference 1 Address *

Reference 1 Phone *

Reference 1 Relationship *

Reference 2 Name *

Reference 2 Address *

Reference 2 Phone *

Reference 2 Relationship *

Reference 3 Name *

Reference 3 Address *

Reference 3 Phone *

Reference 3 Relationship *

Background

Lima Memorial Health System procedure mandates background checks.

Have you been convicted of a felony? *

Yes

If you have been convicted of a felony, please explain.

Have you ever been convicted of any crime involving dishonesty, moral misconduct, or the sale or abuse of a controlled substance (drugs)? *

Yes

If yes, please explain.

Have you been a resident of Ohio for 5 years or more? *

Yes

Authorization and Membership Request

Terms and Conditions *

Yes, I agree to the above terms and conditions.

Instructions

Form Submissions

Please wait for the Thank You page to confirm your form has been submitted.

Community Relations

Featured Services

Cancer Institute

Heart and Vascular Institute

Same-Day Cardiology Appointments

Lima Memorial Physicians

You will need Adobe® Acrobat® Reader to view PDF documents. Download a free copy from the Adobe Web site.