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THE AMERICAN NATIONAL RED CROSS NURSING SERVICE
Form 1037
Rev. 1-24-36.
Application for Enrollment
(To be out and each fully.)
filled entirely in applicant's handwriting question answered
1. Name of applicant in full
Rong
If married, give maiden name
Kalloch
*2.
Permanent address in full
362 Clinton Ave. Newark U.S.
Date of birth June 29 V1901 Race wh Place of birth Thomastor Mame Amitoy, n.g.
Probable address for one year Subs Visiting Earth Ambry-Carteret Chop a.r.c.,
Pert
3.
(Month) (Day) (Year)
Birthplace of father
u.s.a.
Mother u.s.a
Citizenship of father u.s.a.
Are you a citizen of the United States?
yes
4.
Are you single, married, a widow, or divorced?
Married
5. How many years have you attended Grammar School? 4 High school? 2 Normal school?
Private school? 2 College? 1 If tutored privately, name subjects covered and length
of time
6.
What languages other than English do you speak?
None
(Underline those which you speak fluently)
7. Occupation before entering school of nursing
None
8.
From what school of nursing did you receive your diploma? Rochester general Hospital
City and State Rochestis General? my yes) Date Special? of graduation
Oct 20 1923
9. Character of Hospital:
Private?
10. Did your training include medical and surgical care of men? yes
Of women? yes
12. Name and address of director of school of nursing under whom you received training
11. Daily average number of patients in hospital during training 250 Length of course 3 years
Pediatrics? yes Obstetrics? yes Communicable diseases? yea
Miss Cunice a. Smith
(not Known)
13. If your education 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 District and
State Associations?
yes.,1
Diat #1
Affiliation with the American Nurses' Association means active in a District and Graduate Nurses' Association.
16.
Give name and address of secretary of the District or State Association of which you are a
17. Are you a registered nurse) yes In what State? N.Y. Date of registration 1923 Number 41198
member Mrs. agnes R. Pgeiger 32 Elmwood are Union n.g.
18. Type of work and length of service since graduation:
frivate duty 1 weav -
them Uniting Nurse Service S (Syeana ii all)
Post graduate 31 Containing Sydonham Hospital Baltimore the mos.
19. Are you willing to accept service if the United States becomes involved in war?
no
Or, service with the American Red Cross in time of disaster or great emergency?
Mo
Check to indicate whether you would prefer assignment with the Army Nurse Corps
or Navy Nurse Corps
and
20. Are you willing to take the oath of allegiance?
yes
21. Are you a qualified public health nurse, or teacher?
pept
If so, please answer the questions on the reverse side of this blank.
yes.
22.
Give name and permanent address of nearest relative or friend, residing in the United States
(state relationship).
Husband.
NEW BRUWS WINK , Ernest REC'D Date mary 1. 19 1938 hang 1937 Signature - 362 of Nurse Cluston Gsthw are K Newark Loona? n.g.
*Addresses must be given in full, including street, city and state.
(OVER)
Page data
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"ocrText": "THE AMERICAN NATIONAL RED CROSS NURSING SERVICE\nForm 1037\nRev. 1-24-36.\nApplication for Enrollment\n(To be out and each fully.)\nfilled entirely in applicant's handwriting question answered\n1. Name of applicant in full\nRong\nIf married, give maiden name\nKalloch\n*2.\nPermanent address in full\n362 Clinton Ave. Newark U.S.\nDate of birth June 29 V1901 Race wh Place of birth Thomastor Mame Amitoy, n.g.\nProbable address for one year Subs Visiting Earth Ambry-Carteret Chop a.r.c.,\nPert\n3.\n(Month) (Day) (Year)\nBirthplace of father\nu.s.a.\nMother u.s.a\nCitizenship of father u.s.a.\nAre you a citizen of the United States?\nyes\n4.\nAre you single, married, a widow, or divorced?\nMarried\n5. How many years have you attended Grammar School? 4 High school? 2 Normal school?\nPrivate school? 2 College? 1 If tutored privately, name subjects covered and length\nof time\n6.\nWhat languages other than English do you speak?\nNone\n(Underline those which you speak fluently)\n7. Occupation before entering school of nursing\nNone\n8.\nFrom what school of nursing did you receive your diploma? Rochester general Hospital\nCity and State Rochestis General? my yes) Date Special? of graduation\nOct 20 1923\n9. Character of Hospital:\nPrivate?\n10. Did your training include medical and surgical care of men? yes\nOf women? yes\n12. Name and address of director of school of nursing under whom you received training\n11. Daily average number of patients in hospital during training 250 Length of course 3 years\nPediatrics? yes Obstetrics? yes Communicable diseases? yea\nMiss Cunice a. Smith\n(not Known)\n13. If your education as a nurse was received in more than one hospital, give name, location and\ntime spent in each\n14. Are you a member of your Alumnae Association?\nyes\n15.\nAre you affiliated with the American Nurses' Association through membership in District and\nState Associations?\nyes.,1\nDiat #1\nAffiliation with the American Nurses' Association means active in a District and Graduate Nurses' Association.\n16.\nGive name and address of secretary of the District or State Association of which you are a\n17. Are you a registered nurse) yes In what State? N.Y. Date of registration 1923 Number 41198\nmember Mrs. agnes R. Pgeiger 32 Elmwood are Union n.g.\n18. Type of work and length of service since graduation:\nfrivate duty 1 weav -\nthem Uniting Nurse Service S (Syeana ii all)\nPost graduate 31 Containing Sydonham Hospital Baltimore the mos.\n19. Are you willing to accept service if the United States becomes involved in war?\nno\nOr, service with the American Red Cross in time of disaster or great emergency?\nMo\nCheck to indicate whether you would prefer assignment with the Army Nurse Corps\nor Navy Nurse Corps\nand\n20. Are you willing to take the oath of allegiance?\nyes\n21. Are you a qualified public health nurse, or teacher?\npept\nIf so, please answer the questions on the reverse side of this blank.\nyes.\n22.\nGive name and permanent address of nearest relative or friend, residing in the United States\n(state relationship).\nHusband.\nNEW BRUWS WINK , Ernest REC'D Date mary 1. 19 1938 hang 1937 Signature - 362 of Nurse Cluston Gsthw are K Newark Loona? n.g.\n*Addresses must be given in full, including street, city and state.\n(OVER)"
}