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DMR1
N
THE AMERICAN RED CROSS
DEPARTMENT OF NURSING
let
Application for Enrollment
(To be filled out entirely in applicant's handwriting and each question answered fully)
1. Name
2. Address in full, Street Park are
of applicant in full Bertha Sornelia maugle
Mrs.
City Roaring spering State
Pa
36 4. Are you married, single widow? Single Are you a citizen of the United States? yes,
3. Date of birth January 27, 1882 Place of birth Erkrett
or a
5. Have you any physical defects or tendency to constitutional or pulmonary trouble?
none
Are you physically strong and healthy?
yes
6. Name educational institutions attended before-entering training school, stating number of years at each and from
Houston,
which you were graduated Graduated at Everett stight school 1900
7. What languages other than English do you speak? none
8.
Occupation before entering training school clerk and Buyer in Dept. Store
9.
From
ON
what hospital training school did you receive your diploma? The nasour Hospital
City and
state Roaring spring Pa Date of graduation June 122-1909
10.
Character of hospital: General? General Special?
Private?
11. Did your training include obstetrics? yes Care of men? yes Children? yest Contagious diseases? yes
12. Daily average number of patients in hospital during training
Length of course 2yrs
13. Name and address of superintendent of training school under whom you received training
miss alire m. Bayer, university strapital stansan City tro.
14. If your training as a nurse wag received in more than one hospital, give name, location and time spent in each.
15. Of what nursing organizations are you a member?
Look 3 months Post Graduate course in Surgical work at
The nason stospital alumin
Grace staffital, Detroit
16. Which, if any, is affiliated with the American Nurses Association?
-
17. name at one these
Give and address of secretary of least of organizations Bertha C maugle
18. Are you a registered nurse? yes In what state? Pema .Date of registration Deu18 1909 Number
it.
19. How and where employed since graduation:
Give dates with months.
Name and address of employers:
# 490
until mar 14, 1917.
Did private nursing
pnice Sept 6-1917 hard
look Surgical nursing
manit-funce 14,
Grace Hospital. Detroit,
been assistant the Sept of nurses, with charge of operating
Room at nadon
Hupital
(Specify for which of the following services you wish to be considered.)
20. War service, wherever needed Warpervice
When available
September 1st,
U
Are you willing to take the oath of allegiance? yes
21. Instructor, Elementary Hygiene -
22. Public Health Nursing
-
In Town and Country Nursing Service.
or for War Service.
8
23.
Name and permanent address of nearest relative mrs Adettie maugle
Date Jane 11-1918
Everett Bedford Co
Pa
Signature of Nurse Bertha C maugle
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, 29, and A. R. C.
703. Application 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, 11 and 29, should be for-
warded to the Chairman, Department of Nursing, 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.
1M-March
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Document data
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"ocrText": "DMR1\nN\nTHE AMERICAN RED CROSS\nDEPARTMENT OF NURSING\nlet\nApplication for Enrollment\n(To be filled out entirely in applicant's handwriting and each question answered fully)\n1. Name\n2. Address in full, Street Park are\nof applicant in full Bertha Sornelia maugle\nMrs.\nCity Roaring spering State\nPa\n36 4. Are you married, single widow? Single Are you a citizen of the United States? yes,\n3. Date of birth January 27, 1882 Place of birth Erkrett\nor a\n5. Have you any physical defects or tendency to constitutional or pulmonary trouble?\nnone\nAre you physically strong and healthy?\nyes\n6. Name educational institutions attended before-entering training school, stating number of years at each and from\nHouston,\nwhich you were graduated Graduated at Everett stight school 1900\n7. What languages other than English do you speak? none\n8.\nOccupation before entering training school clerk and Buyer in Dept. Store\n9.\nFrom\nON\nwhat hospital training school did you receive your diploma? The nasour Hospital\nCity and\nstate Roaring spring Pa Date of graduation June 122-1909\n10.\nCharacter of hospital: General? General Special?\nPrivate?\n11. Did your training include obstetrics? yes Care of men? yes Children? yest Contagious diseases? yes\n12. Daily average number of patients in hospital during training\nLength of course 2yrs\n13. Name and address of superintendent of training school under whom you received training\nmiss alire m. Bayer, university strapital stansan City tro.\n14. If your training as a nurse wag received in more than one hospital, give name, location and time spent in each.\n15. Of what nursing organizations are you a member?\nLook 3 months Post Graduate course in Surgical work at\nThe nason stospital alumin\nGrace staffital, Detroit\n16. Which, if any, is affiliated with the American Nurses Association?\n-\n17. name at one these\nGive and address of secretary of least of organizations Bertha C maugle\n18. Are you a registered nurse? yes In what state? Pema .Date of registration Deu18 1909 Number\nit.\n19. How and where employed since graduation:\nGive dates with months.\nName and address of employers:\n# 490\nuntil mar 14, 1917.\nDid private nursing\npnice Sept 6-1917 hard\nlook Surgical nursing\nmanit-funce 14,\nGrace Hospital. Detroit,\nbeen assistant the Sept of nurses, with charge of operating\nRoom at nadon\nHupital\n(Specify for which of the following services you wish to be considered.)\n20. War service, wherever needed Warpervice\nWhen available\nSeptember 1st,\nU\nAre you willing to take the oath of allegiance? yes\n21. Instructor, Elementary Hygiene -\n22. Public Health Nursing\n-\nIn Town and Country Nursing Service.\nor for War Service.\n8\n23.\nName and permanent address of nearest relative mrs Adettie maugle\nDate Jane 11-1918\nEverett Bedford Co\nPa\nSignature of Nurse Bertha C maugle\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, 29, and A. R. C.\n703. Application forms (except of a nurse desiring to enroll for the Town and Country Nursing Service) after approval\nand endorsement by Local Committee, with credentials (Forms 3 and 4), together with Forms 10, 11 and 29, should be for-\nwarded to the Chairman, Department of Nursing, 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\nthe\nLocal Committee, instead of to Washington, as instructed, such forms should be forwarded at once to Washington by the\nLocal Committee. from whence credentials will be procured.\n1M-March"
}