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Form 1037
Rev. 12-1-26
THE AMERICAN NATIONAL RED CROSS NURSING SERVICE
Mrs.
Application for Enrollment
I
(To be filled out entirely in applicant's handwriting and each question answered fully.)
M
1. Name of applicant in full
a
2.
Address in full 876 Dayton Ohio
vit
3.
white Dayton Chip
M
4
a
4. single 4 school? yes
Are Date Birthplace you of birth married, of august fathe single Dayton or (a widow? 1905 Mother Race Dayton Are you a citizen Place Citizenship of of the birth United of States?
(b
5. How many years have you attended grammar school? 8 High school? Normal
Private school?
College?
if tutured privately, name subjects covered and length of time
M.
6. What languages other than English do you speak? none
M
L
7. Occupation before entering training school student (Underline those which you speak fluently)
8.
From what hospital training school did you receive your diploma? miami Valley Hospital
at
3
City Give and name State at time startion, of graduation Ohio Maude marie may Private?
Date of graduation 12, 1926
e
9. Character of hospital: General?
Special?
10. Did your training include obstetrics? yest Care of men ryes Children? yes Contagious diseases? 3 yes
MJ
11.
Daily average number of patients in hospital during traiging 320 length
of
course
E
12. Name and address of superintendent of nurses under whom you received training
years
miss Lillian a Hanford - new york
S
13. If your training as a nurse was received in more than one hospital, give name, location and time spent
5
in each
14.
15. Are you affiliated with the American Nurses Association through membership in Alumnae, District
Are you a member of your Alumnae Association? yes
5
p
16. Give name and address of secretary of at deast one of these organizations
and State Associations? yes
&
17. midren July Are you a registered nurse? yes 415 in what State? Ohio Date of registration Number 10,872
5
18. Type of work and length of fiseryice since graduation:
Private outy
ftead nurse - month It
Industriel-Fregden - month
(Present position)
19. Will you be willing to accept active service if the United States becomes involved in war? yes
Private Duty
20.
(a) If interested in accepting service within the near future, indicate choice: R. C.P.H. Nursing, Instructor,
Home Hygiene and Care of Sick, Army, Navy, U. S. Public Health Service, U. S. Veterans' Bureau.
4
(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
w
relationship) Miss Laura Olt (aunt) 876 Rivervely Ave
NOTE-Nutses Date April 15,1929 who have had training or Signature experience in Public of nurse Health Nursing mande will, in addition Marie to the above, fill out tellough questions 23 and/24 on
150
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)
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"ocrText": "T\n+\nForm 1037\nRev. 12-1-26\nTHE AMERICAN NATIONAL RED CROSS NURSING SERVICE\nMrs.\nApplication for Enrollment\nI\n(To be filled out entirely in applicant's handwriting and each question answered fully.)\nM\n1. Name of applicant in full\na\n2.\nAddress in full 876 Dayton Ohio\nvit\n3.\nwhite Dayton Chip\nM\n4\na\n4. single 4 school? yes\nAre Date Birthplace you of birth married, of august fathe single Dayton or (a widow? 1905 Mother Race Dayton Are you a citizen Place Citizenship of of the birth United of States?\n(b\n5. How many years have you attended grammar school? 8 High school? Normal\nPrivate school?\nCollege?\nif tutured privately, name subjects covered and length of time\nM.\n6. What languages other than English do you speak? none\nM\nL\n7. Occupation before entering training school student (Underline those which you speak fluently)\n8.\nFrom what hospital training school did you receive your diploma? miami Valley Hospital\nat\n3\nCity Give and name State at time startion, of graduation Ohio Maude marie may Private?\nDate of graduation 12, 1926\ne\n9. Character of hospital: General?\nSpecial?\n10. Did your training include obstetrics? yest Care of men ryes Children? yes Contagious diseases? 3 yes\nMJ\n11.\nDaily average number of patients in hospital during traiging 320 length\nof\ncourse\nE\n12. Name and address of superintendent of nurses under whom you received training\nyears\nmiss Lillian a Hanford - new york\nS\n13. If your training as a nurse was received in more than one hospital, give name, location and time spent\n5\nin each\n14.\n15. Are you affiliated with the American Nurses Association through membership in Alumnae, District\nAre you a member of your Alumnae Association? yes\n5\np\n16. Give name and address of secretary of at deast one of these organizations\nand State Associations? yes\n&\n17. midren July Are you a registered nurse? yes 415 in what State? Ohio Date of registration Number 10,872\n5\n18. Type of work and length of fiseryice since graduation:\nPrivate outy\nftead nurse - month It\nIndustriel-Fregden - month\n(Present position)\n19. Will you be willing to accept active service if the United States becomes involved in war? yes\nPrivate Duty\n20.\n(a) If interested in accepting service within the near future, indicate choice: R. C.P.H. Nursing, Instructor,\nHome Hygiene and Care of Sick, Army, Navy, U. S. Public Health Service, U. S. Veterans' Bureau.\n4\n(b) Date upon which you will be available for service checked\n21. Are you willing to take the oath of allegiance? yes\n22. Give name and permanent address of nearest relative or friend, residing in the United States (state\nw\nrelationship) Miss Laura Olt (aunt) 876 Rivervely Ave\nNOTE-Nutses Date April 15,1929 who have had training or Signature experience in Public of nurse Health Nursing mande will, in addition Marie to the above, fill out tellough questions 23 and/24 on\n150\nreverse side\nof\nthis 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 be forwarded to\nNational Headquarters or to the proper Branch Office.\n(OVER)"
}