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D. M. R.-1
AMERICAN RED CROSS
(CROIX-ROUGE AMÉRICAINE)
ÉLYSÉES 43-82
ADRESSE TÉLÉGRAPHIQUE :
43-83
TÉLÉPHONE
"
43-88
AMCROSS
43-89
4, PLACE DE LA CONCORDE
NURSING SERVICE
PARIS,
APPLICATION FOR ENROLLMENT
(To be filled out entirely in applicant's handwriting and each question answered fully)
1. Name of applicant in full
2.
Address
in
Street
11
his
Josychins statue Sunvalofea, Paris go kaitis
full,
KletuCity
France
State
ing
3.
Date
of birth november 24-1885
Place of
birth Posen Poland
4. Are you married, single or a widow ?
Widow
Are you a citizen of the United States ?
5. Have you any physical defects or tendency to constitutional or pulmonary trouble ?
no
Yes
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
It StanisPaus parochial School- Chipo Schio School of Ciris +
Itoly Family academy lur- ( Chigo )
7. What languages other than English do you speak ?
Polish
Thirantrophy winter Summer 1914-) curree 1915
riming cinibe
8. Occupation before entering training school
Book keeping
9. From what hospital training school did you receive your diploma ? Janover Hospital -
City and state milwaukee wis.
Date of graduation Drs. 20-1906
10. Character of hospital : General?
Special ?
Private ?
11. Did your training include obstetrics ? yes
Care
of
men
?
yes
Children ? yes
Contagious diseases ?
12. Daily average number of patients in hospitals during training
30-
Length
of
course
2
13. Name and address of superintendent of training school under whom you received training m. E. Rikkers
yrs.
14.
Leavitt and Themas Stio. Chip. (150 beds- 1yr. 1903-1904
If your training as a nurse was received in more than one hospital, give name, location and time spent in each St. mary's Itosp.
15. Of what
nursing organizations are you a member ? national Organization for Publis Stealth
nursing .
16. Which, if any, is affiliated with the American Nurses Association ?
above
17. Give name and address of secretary of at least one of these organizations miss Ella Phillips Crandull_
5th SWE new You're city -
OK
18. Are you a registered nurse ? yes-
In what state ? Illinois
Date of registration march 4-1910
19. State how, where and for what period of time, in each instance, you have been employed since graduation, including present employment,
giving name and address of persons in charge Left hosp. June - 1907- Private duty
Temp Supt Tuberculoris Sanatorium Blue mound his- -
Visiting nurse asin Chicago. march 101 1908 to- Sept- 1915 Supt.
Industrial welfare nurse Ill's Steel Co. Tary Ind. Oct. 1-1915 July 1918-
July until present time in charge- of the Phish unit -
Polish national Comittee 11fis Strence Kleber- Paris Funce -
(Specify for which of the following services you wish to be considered.)
20. War service, wherever needed
U. S. only
When available
Are you willing to take the oath of allegiance ?
21. Instructor, Elementary Hygiene
Home Dietetics
Surgical Dressings
22. Public Health Nursing in Town and Country Nursing Service
23. Name
1510 Selton Stue.
and permanent address of nearest relative Joseph Snivalski (father)
Chqo
Hls.
Date Jan -
'19
Signature
Josephine Johnaitis
To the Committee :
This blank is to be sent to applicant with circular letter D. M. R. 7, together with Forms D. M. R. 2, 11, and A. R. C. 150. Appli-
cation forms (except of a nurse desiring to enroll for the Town and Country Nursing Service) after approval and endorsement by Local
Committee, with credentials (Forms 3 and 4) together with Forms 10 and 11, should be forwarded to the Chairman, National Committee on
Nursing Service, American Red Cross, Washington, D. C.
In case the application forms of a nurse desiring to enroll for the Town and Country Nursing Service are sent to the Local Committee,
instead of to Washington, as instructed, such forms should be forwarded at once to Washington by the Local Committee, from whence credentials
will be procured.
Page data
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- Source index
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- Type
- photo
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Document data
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- Core
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- Type
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DTO data
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"ocrText": "D. M. R.-1\nAMERICAN RED CROSS\n(CROIX-ROUGE AMÉRICAINE)\nÉLYSÉES 43-82\nADRESSE TÉLÉGRAPHIQUE :\n43-83\nTÉLÉPHONE\n\"\n43-88\nAMCROSS\n43-89\n4, PLACE DE LA CONCORDE\nNURSING SERVICE\nPARIS,\nAPPLICATION FOR ENROLLMENT\n(To be filled out entirely in applicant's handwriting and each question answered fully)\n1. Name of applicant in full\n2.\nAddress\nin\nStreet\n11\nhis\nJosychins statue Sunvalofea, Paris go kaitis\nfull,\nKletuCity\nFrance\nState\ning\n3.\nDate\nof birth november 24-1885\nPlace of\nbirth Posen Poland\n4. Are you married, single or a widow ?\nWidow\nAre you a citizen of the United States ?\n5. Have you any physical defects or tendency to constitutional or pulmonary trouble ?\nno\nYes\nAre you physically strong and healthy ?\nyes -\n6.\nName educational institutions attended before entering training school, stating number of years at each and from which you were graduated\nIt StanisPaus parochial School- Chipo Schio School of Ciris +\nItoly Family academy lur- ( Chigo )\n7. What languages other than English do you speak ?\nPolish\nThirantrophy winter Summer 1914-) curree 1915\nriming cinibe\n8. Occupation before entering training school\nBook keeping\n9. From what hospital training school did you receive your diploma ? Janover Hospital -\nCity and state milwaukee wis.\nDate of graduation Drs. 20-1906\n10. Character of hospital : General?\nSpecial ?\nPrivate ?\n11. Did your training include obstetrics ? yes\nCare\nof\nmen\n?\nyes\nChildren ? yes\nContagious diseases ?\n12. Daily average number of patients in hospitals during training\n30-\nLength\nof\ncourse\n2\n13. Name and address of superintendent of training school under whom you received training m. E. Rikkers\nyrs.\n14.\nLeavitt and Themas Stio. Chip. (150 beds- 1yr. 1903-1904\nIf your training as a nurse was received in more than one hospital, give name, location and time spent in each St. mary's Itosp.\n15. Of what\nnursing organizations are you a member ? national Organization for Publis Stealth\nnursing .\n16. Which, if any, is affiliated with the American Nurses Association ?\nabove\n17. Give name and address of secretary of at least one of these organizations miss Ella Phillips Crandull_\n5th SWE new You're city -\nOK\n18. Are you a registered nurse ? yes-\nIn what state ? Illinois\nDate of registration march 4-1910\n19. State how, where and for what period of time, in each instance, you have been employed since graduation, including present employment,\ngiving name and address of persons in charge Left hosp. June - 1907- Private duty\nTemp Supt Tuberculoris Sanatorium Blue mound his- -\nVisiting nurse asin Chicago. march 101 1908 to- Sept- 1915 Supt.\nIndustrial welfare nurse Ill's Steel Co. Tary Ind. Oct. 1-1915 July 1918-\nJuly until present time in charge- of the Phish unit -\nPolish national Comittee 11fis Strence Kleber- Paris Funce -\n(Specify for which of the following services you wish to be considered.)\n20. War service, wherever needed\nU. S. only\nWhen available\nAre you willing to take the oath of allegiance ?\n21. Instructor, Elementary Hygiene\nHome Dietetics\nSurgical Dressings\n22. Public Health Nursing in Town and Country Nursing Service\n23. Name\n1510 Selton Stue.\nand permanent address of nearest relative Joseph Snivalski (father)\nChqo\nHls.\nDate Jan -\n'19\nSignature\nJosephine Johnaitis\nTo the Committee :\nThis blank is to be sent to applicant with circular letter D. M. R. 7, together with Forms D. M. R. 2, 11, and A. R. C. 150. Appli-\ncation forms (except of a nurse desiring to enroll for the Town and Country Nursing Service) after approval and endorsement by Local\nCommittee, with credentials (Forms 3 and 4) together with Forms 10 and 11, should be forwarded to the Chairman, National Committee on\nNursing Service, American Red Cross, Washington, D. C.\nIn case the application forms of a nurse desiring to enroll for the Town and Country Nursing Service are sent to the Local Committee,\ninstead of to Washington, as instructed, such forms should be forwarded at once to Washington by the Local Committee, from whence credentials\nwill be procured."
}