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Form 1037
THE AMERICAN NATIONAL RED CROSS NURSING SERVICE
Rev. 4-15-30
Application for Enrollment
ath
active
(To be filled out entirely in applicant's handwriting and each question answered fully.)
1. Name of applicant in full
Pattenic forgythe
2. Permanent address in full
413 marle Belling un ,
Mrs.
Probable address for one year
same
V2 3. Date of birth aug (Month) (Day) 7 (Year) 1909 Race white
Place birth Minn
of
Birthplace
of father Canada Mother SmithDated Citizenship of father am -
K
4.
Are you married, single or a widow ? single Are you a citizen of the United States?
yes
Fit
5. How many years have you attended Grammar school? 8 High school ? 4 Normal school
.O
5
Private school?
0
College? 2 If tutored privately, name subjects covered and length of
time
trunch
2 years
6. What languages other than English do you speak?
french
(Underline those which you speak fluently)
7. Occupation before entering training school
student
8. From what hospital training school did you receive your diploma?
City and State Sealtte
Date of graduation May 930
Seattle general
the
e
Give name at time of graduation
9. Character of Hospital General? general Special?
altheme Jossyatic Private?
10.
Daily average number of patients in hospital during training 100
Did your training include obstetrics? yescare Care of men? yeshildrenzyed Contagious diseases? 3 yes
11.
Length of course
12. Name and address of superintendent of nurses under whom you received training
yethers
miss Evelyn Hall Harbmin-Hospited Seattle, un.
13. If your training as a nurse was received in more than one hospital, give name, location and time spent in
each
14. Are you a member of your Alumnae Association?
yes.
15. Are you affiliated with the American Nurses' Association through membership in Alumnae, District and
State Associations?
Affiliation with the American Nurses' Association means membership in the District and Graduate Nurses' Associations of the state
yes.
in which you are living at the present time.
16.
Give name and address of secretary of the District or State Association of which you are a member
Miss Bertha Lu secretary of 1st dist. asm. YuDr.S.H Johnson
17. Are you a registered nurse yes In what State W n. Date of registration 193 0
18. Type of work and length of service since graduation :
Seatte for 1 year- Public student
technician and nurse. Dr. C.H. Health
Billinghas en
at u. of Wn. 9 mu- - 8 mo at Visiting nurse assu.
(Present position)
staff nurse of Bellanglosm involved visiting in war kurse asm
19.
Will you be willing to accept service if the United States )becomes yes
20. (a) If interested in accepting service within the near future, indicate choice : R.C.P.H. Nursing; Instruc-
tor, Home Hygiene and Care of Sick; Army Navy; U. S. Public Health Service; U. S. Veterans
Bureau.
(b) Date upon which you will be available for service checked
21. Are you willing to take the oath of allegiance?
yes,
22. Give name and permanent address of nearest relative or friend, residing in the United States (state rela-
(mother) tionship) his Charlotte proyette 502 Easttake Seattle
Date. 6-15-32 Signature of nurse
IT allienin forrytts out
NOTE-Nurses who have had training or experience in Public Health Nursing will, in addition to the above, questions
23
and 24 on reverse side of this blank.
To the Local Committee:
This blank is to be sent to applicant with circular letter Form 1199, together with Forms 2, 1193 and A. R. C. 703.
Application forms after approval and endorsement by Local Committee, with Forms 1244, 1189, and 1193 should
be
forwarded to National Headquarters or to the proper Branch Office.
(OVER)
5
Page data
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Document data
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- Type
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Context sent to Scholar
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"ocrText": "ID\nere\nen\nB\n0\nForm 1037\nTHE AMERICAN NATIONAL RED CROSS NURSING SERVICE\nRev. 4-15-30\nApplication for Enrollment\nath\nactive\n(To be filled out entirely in applicant's handwriting and each question answered fully.)\n1. Name of applicant in full\nPattenic forgythe\n2. Permanent address in full\n413 marle Belling un ,\nMrs.\nProbable address for one year\nsame\nV2 3. Date of birth aug (Month) (Day) 7 (Year) 1909 Race white\nPlace birth Minn\nof\nBirthplace\nof father Canada Mother SmithDated Citizenship of father am -\nK\n4.\nAre you married, single or a widow ? single Are you a citizen of the United States?\nyes\nFit\n5. How many years have you attended Grammar school? 8 High school ? 4 Normal school\n.O\n5\nPrivate school?\n0\nCollege? 2 If tutored privately, name subjects covered and length of\ntime\ntrunch\n2 years\n6. What languages other than English do you speak?\nfrench\n(Underline those which you speak fluently)\n7. Occupation before entering training school\nstudent\n8. From what hospital training school did you receive your diploma?\nCity and State Sealtte\nDate of graduation May 930\nSeattle general\nthe\ne\nGive name at time of graduation\n9. Character of Hospital General? general Special?\naltheme Jossyatic Private?\n10.\nDaily average number of patients in hospital during training 100\nDid your training include obstetrics? yescare Care of men? yeshildrenzyed Contagious diseases? 3 yes\n11.\nLength of course\n12. Name and address of superintendent of nurses under whom you received training\nyethers\nmiss Evelyn Hall Harbmin-Hospited Seattle, un.\n13. If your training as a nurse was received in more than one hospital, give name, location and time spent in\neach\n14. Are you a member of your Alumnae Association?\nyes.\n15. Are you affiliated with the American Nurses' Association through membership in Alumnae, District and\nState Associations?\nAffiliation with the American Nurses' Association means membership in the District and Graduate Nurses' Associations of the state\nyes.\nin which you are living at the present time.\n16.\nGive name and address of secretary of the District or State Association of which you are a member\nMiss Bertha Lu secretary of 1st dist. asm. YuDr.S.H Johnson\n17. Are you a registered nurse yes In what State W n. Date of registration 193 0\n18. Type of work and length of service since graduation :\nSeatte for 1 year- Public student\ntechnician and nurse. Dr. C.H. Health\nBillinghas en\nat u. of Wn. 9 mu- - 8 mo at Visiting nurse assu.\n(Present position)\nstaff nurse of Bellanglosm involved visiting in war kurse asm\n19.\nWill you be willing to accept service if the United States )becomes yes\n20. (a) If interested in accepting service within the near future, indicate choice : R.C.P.H. Nursing; Instruc-\ntor, Home Hygiene and Care of Sick; Army Navy; U. S. Public Health Service; U. S. Veterans\nBureau.\n(b) Date upon which you will be available for service checked\n21. Are you willing to take the oath of allegiance?\nyes,\n22. Give name and permanent address of nearest relative or friend, residing in the United States (state rela-\n(mother) tionship) his Charlotte proyette 502 Easttake Seattle\nDate. 6-15-32 Signature of nurse\nIT allienin forrytts out\nNOTE-Nurses who have had training or experience in Public Health Nursing will, in addition to the above, questions\n23\nand 24 on reverse side of this blank.\nTo the Local Committee:\nThis blank is to be sent to applicant with circular letter Form 1199, together with Forms 2, 1193 and A. R. C. 703.\nApplication forms after approval and endorsement by Local Committee, with Forms 1244, 1189, and 1193 should\nbe\nforwarded to National Headquarters or to the proper Branch Office.\n(OVER)\n5"
}