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DMR1
THE AMERICAN RED CROSS
DEPARTMENT OF NURSING
Application for Enrollment
(To be filled out entirely in applicant's handwriting and each question answered fully)
1. Name of applicant in full Sara m Gray
3. Date of birth hlee 23 1886.
2. Address in full, Street. 1564 Crotona TarkE City Brount by State n.y
32
Place of birth Island
4. Are you married, single or a widow? Single
Are you a citizen of the United States? no
5. Have you any physical defects or tendency to constitutional or pulmonary trouble? no
Are you physically strong and healthy? yes
6. Name educational institutions attended before entering training school, stating number of years at each and from which
you
were graduated. relly man national School
9 yrs
7. What languages other than English do you speak?
houl
8.
Occupation before entering training school Companionism / Training School of
o.k
9. From what hospital training school did you receive your diploma ?/he my Skin a Cander Hospital
City and state n.y. n.
Date of graduation aug. 1916
10. Character of hospital : General?
-
Special? yes
Private?
11. Did your training include obstetrics? ye Care of men? yes Children? yes Contagious diseases? no
12. Daily average number of patients in hospital during training
95
Length of course 2%2 yrs
13. Name and address of superintendent of training school under whom you received training.
miss S. Burns. 301 E. 19 st n y City
-
14. If your training as a nurse was received in more than one hospital, give name, location and time spent in each tordham
Hospital. 6 months, Brony Seying In Hospital 14 ans n-ye 3 months
15. Of what nursing organizations are you a member? Brony a manhatten Club
16 Which, if any, is affiliated with the American Nurses Association? Brong & manhatten Club
for nurses. Bulkley Training School of the in y. S&C. Hosfital alemin
17. Give name and address of secretary of at least one of these organizations miss Beckwity
13281 45 St. 4. y City ( 33 4 m Club)
ih
18. Are you a registered nurse? yes In what state. n.y Date of registration T-eb 14 19th 14448
19. How and where employed since graduation
Give dates with months
Name and address of employers :
sl.
assis up Room hural
Sept 1-1916-to hrs Hillyer
at Union H osputal
Jan 15 19.7
2 57 Valentine are Brone
Trivate hursing
Feb 1914 -To may
34 Framercy Park
914
miss S Burns
in y City.(hly w Bainbridge
Ug Room Supervisor at
San 1918
may 1917 to
the n.y Sc.C Hospital
301 E19 St City
Private nursing
Jan 1918 topreced
Why g Semken 16W85St
thans
n f City
20. War (Specify service, wherever needed Foreign Preferedchen available June 20 th 1918
for which of the following services you wish to be considered.)
Are you willing allegiance? yes
to take the oath of
21. Instructor, Elementary Hygiene
no
22. Public Health Nursing
no In Town and Country Nursing Service no or for War Service yes
23. Name and permanent address of nearest relative mr m Suedden
1564 Crotona Park E. Brony. n. y City
Date June 8th1918
Signature of Nurse S. m. They
To the Committee:
and endorsement by Local Committee, with credentials (Form 3 and 4), together with Forms 10, 11 and 29, Red Cross,
C. 703. Application forms (except of a nurse desiring to enroll for the Town and Country Nursing Service) should be for-
This blank is to be sent to applicant with circular letter D. M. R. 7, together with Forms D. M. R. 2, 11, after 29 and approval A. R.
warded through the Director of the Bureau of Nursing in your Division to the Department of Nursing, American
Washington, D. C.
Local Committee, instead of to Washington, as instructed, such forms should be forwarded at once to Washington by
In case the application forms of a nurse desiring to enroll for the Town and Country Nursing Service are sent to the the
Local Committee, from whence credentials will be procured.
(SEE OTHER SIDE)
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"ocrText": "DMR1\nTHE AMERICAN RED CROSS\nDEPARTMENT OF NURSING\nApplication for Enrollment\n(To be filled out entirely in applicant's handwriting and each question answered fully)\n1. Name of applicant in full Sara m Gray\n3. Date of birth hlee 23 1886.\n2. Address in full, Street. 1564 Crotona TarkE City Brount by State n.y\n32\nPlace of birth Island\n4. Are you married, single or a widow? Single\nAre you a citizen of the United States? no\n5. Have you any physical defects or tendency to constitutional or pulmonary trouble? no\nAre you physically strong and healthy? yes\n6. Name educational institutions attended before entering training school, stating number of years at each and from which\nyou\nwere graduated. relly man national School\n9 yrs\n7. What languages other than English do you speak?\nhoul\n8.\nOccupation before entering training school Companionism / Training School of\no.k\n9. From what hospital training school did you receive your diploma ?/he my Skin a Cander Hospital\nCity and state n.y. n.\nDate of graduation aug. 1916\n10. Character of hospital : General?\n-\nSpecial? yes\nPrivate?\n11. Did your training include obstetrics? ye Care of men? yes Children? yes Contagious diseases? no\n12. Daily average number of patients in hospital during training\n95\nLength of course 2%2 yrs\n13. Name and address of superintendent of training school under whom you received training.\nmiss S. Burns. 301 E. 19 st n y City\n-\n14. If your training as a nurse was received in more than one hospital, give name, location and time spent in each tordham\nHospital. 6 months, Brony Seying In Hospital 14 ans n-ye 3 months\n15. Of what nursing organizations are you a member? Brony a manhatten Club\n16 Which, if any, is affiliated with the American Nurses Association? Brong & manhatten Club\nfor nurses. Bulkley Training School of the in y. S&C. Hosfital alemin\n17. Give name and address of secretary of at least one of these organizations miss Beckwity\n13281 45 St. 4. y City ( 33 4 m Club)\nih\n18. Are you a registered nurse? yes In what state. n.y Date of registration T-eb 14 19th 14448\n19. How and where employed since graduation\nGive dates with months\nName and address of employers :\nsl.\nassis up Room hural\nSept 1-1916-to hrs Hillyer\nat Union H osputal\nJan 15 19.7\n2 57 Valentine are Brone\nTrivate hursing\nFeb 1914 -To may\n34 Framercy Park\n914\nmiss S Burns\nin y City.(hly w Bainbridge\nUg Room Supervisor at\nSan 1918\nmay 1917 to\nthe n.y Sc.C Hospital\n301 E19 St City\nPrivate nursing\nJan 1918 topreced\nWhy g Semken 16W85St\nthans\nn f City\n20. War (Specify service, wherever needed Foreign Preferedchen available June 20 th 1918\nfor which of the following services you wish to be considered.)\nAre you willing allegiance? yes\nto take the oath of\n21. Instructor, Elementary Hygiene\nno\n22. Public Health Nursing\nno In Town and Country Nursing Service no or for War Service yes\n23. Name and permanent address of nearest relative mr m Suedden\n1564 Crotona Park E. Brony. n. y City\nDate June 8th1918\nSignature of Nurse S. m. They\nTo the Committee:\nand endorsement by Local Committee, with credentials (Form 3 and 4), together with Forms 10, 11 and 29, Red Cross,\nC. 703. Application forms (except of a nurse desiring to enroll for the Town and Country Nursing Service) should be for-\nThis blank is to be sent to applicant with circular letter D. M. R. 7, together with Forms D. M. R. 2, 11, after 29 and approval A. R.\nwarded through the Director of the Bureau of Nursing in your Division to the Department of Nursing, American\nWashington, D. C.\nLocal Committee, instead of to Washington, as instructed, such forms should be forwarded at once to Washington by\nIn case the application forms of a nurse desiring to enroll for the Town and Country Nursing Service are sent to the the\nLocal Committee, from whence credentials will be procured.\n(SEE OTHER SIDE)"
}