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Become a Lima Memorial Volunteer

Become a Lima Memorial Volunteer

Volunteer & Auxiliary Member Application

Please fill out the fields below to apply to become a Lima Memorial Volunteer and Auxiliary Member

MM/DD/YYYY


References

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

(First, Last)
(Street, City, State, Zip Code)
(First, Last)
(Street, City, State, Zip Code)
(First, Last)
(Street, City, State, Zip Code)

Background

Lima Memorial Health System procedure mandates background checks.







Authorization and Membership Request

Lima Memorial Hospital is authorized to obtain information regarding my services & character & release your company, individual and/or organization from all liability, which might result from furnishing same. I hereby authorize any physician, surgeon, or hospital to furnish to Lima Memorial Hospital Volunteer Services any and all information and records relating to my physical and/or mental condition prior to the date hereof. I certify that the answers given by me to the foregoing questions and statements are true and correct. I agree that this hospital shall not be liable in any respect if my volunteer work is terminated because of falsity of statements, answers, or missions made by me on this questionnaire. Lima Memorial Hospital considers all applicants for volunteering without regard to age, sex, color, race, creed, religion, national origin or disability. I am requesting membership in the Lima Memorial Hospital Auxiliary.

Form Submissions

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

 

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