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FORM NO. 1
F
-
ROSS
e
RSHINGTON
+
NURSING SERVICE
ct
5
e
1
APPLICATION FOR ENROLLMENT
(To be filled out entirely in applicant's handwriting)
M
I. Name of applicant in full
make Fletcher
2. Address in full.
Dairn fall. Frellervey - mass.
3.
Date of birth
Oct.1865
Place of birth
1-1
4. Are you married, single or a widow?
Single
5.
Have
you any physical defects or tendency to constitutional or pulmonary trouble? - mar geaces -
Are you a citizen of the United States? yes
nothing mous otherwise
6. Name educational institutions attended before entering training school, stating number of years at each and from which you
were
graduated Elementary schemes- High school - Diplous ((Hyp))
7. Occupation before entering training school
Leaching
8. From what hospital training school did you receive your diploma? Give location of hospital and date of graduation
St. Lukis Hospital. 113 St. & sweetew Am n.y. city
October 1899
9.
If your training as a nurse was received in more than one hospital, give name, location and time spent in each.
Sloane matarity Hospital - 3 months.
IO.
Character of hospital: General? General Special?
Private?
II. Did your training include the care of men? yas Contagious diseases?
Obstetrics? you -
I2. Daily average number of patients in hospital during training about en
Length of course.
3
years
13.
Name and address of superintendent of training school under whom you received training
Mrs. Lily n. Quintard - address not known
14. Of what nursing organizations are you a member? alumua area. of St. Lukis -
natl. Diagung nursius Education aero n.TH, alum. Tescherseth
15. Which, if any, is affiliated with the American Nurses Association? The first
16.
Give name and address of secretary of at least one of these organizations.
miss Isabel STurrant
Teachers college. n. L. n.e
17. Are you a registered nurse? yes
In what state? n.4-
Date of registration 1906 ()) 70-126
18. State how, where and for what period of time, in each instance, you have been employed since graduation, including present
employment Private nure 1999-1904. acch, nic, Surai n.4. 7/1904 11/1904
aur. menistrices Saintenin 4/1905 7/1905: night supe. mi Siuai 7/105-2/1910
Supervisor O.P.D.MD. Sinsi 2/1910/2/1918. small position N.TH. Teachers Call.
2/1913-9/1912. Super. numes new Haren Hospita. new Hareu 11/15/1913-
12/1/1915 Resident nure. g ava Hall school. Welluly 2/28/16-6/7/16.
19. Should our country be involved in war, would you be available for active service?
yes.
20.
Would you be willing to take the oath of allegiance?
you.
21.
What
languages other than English do you speak? Understand German & French putty well.
22. Name and permanent address of nearest relative
speak a little-
mrs. Agnes Fleteber daumuse. mass
Date. may 17 - 1916 Signature mabel Fletcher.
This blank is to be sent to applicant with circular letter Form 7, together with Form 11, and rules governing enrollment. After
approval and endorsement by local Committee to be forwarded with "credentials" (Forms Nos. 3 and 4) together with Forms 10-11 to the
Chairman, National Committee on Red Cross Nursing Service, Washington, D. c.

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Document data

ID: 2661471
Core: doc
Type: document

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"ocrText": "FORM NO. 1\nF\n-\nROSS\ne\nRSHINGTON\n+\nNURSING SERVICE\nct\n5\ne\n1\nAPPLICATION FOR ENROLLMENT\n(To be filled out entirely in applicant's handwriting)\nM\nI. Name of applicant in full\nmake Fletcher\n2. Address in full.\nDairn fall. Frellervey - mass.\n3.\nDate of birth\nOct.1865\nPlace of birth\n1-1\n4. Are you married, single or a widow?\nSingle\n5.\nHave\nyou any physical defects or tendency to constitutional or pulmonary trouble? - mar geaces -\nAre you a citizen of the United States? yes\nnothing mous otherwise\n6. Name educational institutions attended before entering training school, stating number of years at each and from which you\nwere\ngraduated Elementary schemes- High school - Diplous ((Hyp))\n7. Occupation before entering training school\nLeaching\n8. From what hospital training school did you receive your diploma? Give location of hospital and date of graduation\nSt. Lukis Hospital. 113 St. & sweetew Am n.y. city\nOctober 1899\n9.\nIf your training as a nurse was received in more than one hospital, give name, location and time spent in each.\nSloane matarity Hospital - 3 months.\nIO.\nCharacter of hospital: General? General Special?\nPrivate?\nII. Did your training include the care of men? yas Contagious diseases?\nObstetrics? you -\nI2. Daily average number of patients in hospital during training about en\nLength of course.\n3\nyears\n13.\nName and address of superintendent of training school under whom you received training\nMrs. Lily n. Quintard - address not known\n14. Of what nursing organizations are you a member? alumua area. of St. Lukis -\nnatl. Diagung nursius Education aero n.TH, alum. Tescherseth\n15. Which, if any, is affiliated with the American Nurses Association? The first\n16.\nGive name and address of secretary of at least one of these organizations.\nmiss Isabel STurrant\nTeachers college. n. L. n.e\n17. Are you a registered nurse? yes\nIn what state? n.4-\nDate of registration 1906 ()) 70-126\n18. State how, where and for what period of time, in each instance, you have been employed since graduation, including present\nemployment Private nure 1999-1904. acch, nic, Surai n.4. 7/1904 11/1904\naur. menistrices Saintenin 4/1905 7/1905: night supe. mi Siuai 7/105-2/1910\nSupervisor O.P.D.MD. Sinsi 2/1910/2/1918. small position N.TH. Teachers Call.\n2/1913-9/1912. Super. numes new Haren Hospita. new Hareu 11/15/1913-\n12/1/1915 Resident nure. g ava Hall school. Welluly 2/28/16-6/7/16.\n19. Should our country be involved in war, would you be available for active service?\nyes.\n20.\nWould you be willing to take the oath of allegiance?\nyou.\n21.\nWhat\nlanguages other than English do you speak? Understand German & French putty well.\n22. Name and permanent address of nearest relative\nspeak a little-\nmrs. Agnes Fleteber daumuse. mass\nDate. may 17 - 1916 Signature mabel Fletcher.\nThis blank is to be sent to applicant with circular letter Form 7, together with Form 11, and rules governing enrollment. After\napproval and endorsement by local Committee to be forwarded with \"credentials\" (Forms Nos. 3 and 4) together with Forms 10-11 to the\nChairman, National Committee on Red Cross Nursing Service, Washington, D. c."
}

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