Become a Lima Memorial Volunteer

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
No

If so, where are you employed?

Are you a college or high school student? *

Yes
No

If so, what school do you attend?

Business Phone

References

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

Reference 1 Name *

Reference 1 Address *

Reference 1 Phone *

Reference 1 Email *

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
No

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
No

If yes, please explain.

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

Yes
No

Authorization and Membership Request

Terms and Conditions *

Yes, I agree to the above terms and conditions.

Form Submissions

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

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Become a Lima Memorial Volunteer

References

Background

Authorization and Membership Request

Form Submissions

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