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B
RED CROSS BADGE NUMBER
AMERICAN RED CROSS
7125
NURSING SERVICES
2
MILITARY SERIAL NUMBER
ANNUAL QUESTIONNAIRE - 1945
CHECK IF YOUR LAST NAME HAS CHANGED
NAME (Last, first, middle)
TELEPHONE NO.
Brown Hellie Gates
8098 muncie
IF MARRIED, GIVE MAIDEN NAME
HUSBAND'S NAME
PERMANENT ADDRESS (Street, city, zone, county, state) Route 6- - muncie Indiana
PRESENT ADDRESS (Street, city, zone, county, state)
"
NAME AND ADDRESS OF NEAREST RELATIVE OR FRIEND IN THE UNITED STATES
RELATIONSHIP
Miss Lauia 8 Brown Route 6- Minnie Ind.
sister
DATE OF BIRTH (Month, day, year)
Single
July 12- 1885
Married
Separated
Widowed
D1 vorced
WHAT LANGUAGES DO YOU SPEAK?
YES
NO
English
French
(poo)
HIGH SCHOOL GRADUATE
NAME OF COLLEGE OR
DEGREE OR
UNIVERSITY ATTENDED
LOCATION
INCLUSIVE DATES
DIPLOMA
MAJOR
Teachers College tolumbia n.y
331927 Teaching Schools
8 Tursing
ARE YOU CURRENTLY
YES
NO
REGISTERED IN (State)
ARE YOU CURRENTLY A MEMBER OF THE AMERICAN
YES
NO
Indiana
NURSES' ASSOCIATION?
C.
4
REGISTERED?
PRESENT EMPLOYMENT If not employed, check
POSITION TITLE (H.N.; P.D., inst., staff nurse, etc.)
SERVICE (Medicine surgery, etc.)
Supt
CITY
In
NAME OF HOSPITAL OR ORGANIZATION BY WHOM EMPLOYED
STATE
BAll Memoical Hospital Muncie
n
HEALTH
IF OTHER THAN GOOD, SPECIFY NATURE AND ANTICIRATED DURATION OF DISABILITY
Tx
Good.
cillie
VOLUNTEER SERVICE
The purpose of the following statements s to identify theynurses who can be counted upon to respond to a call
to participate in a Red Cross chapter program please check the "Xes" box only if you are willing and able to
serve if called on within the next 12 months.
Co
give
NAME AND ADDRESS OF THE CHAPTER IN WHOSE JURISDICTION YOU EXPECT TO LIVE FOR THE NEXT 12 MONTHS
Minnese
NO Attend an instructors' training program 1f offered. (Funds are available for
Chapter
(E)
94
YES
NO
1. Teach home
YES
nursing classes
training home nursing Instructors. See local chapter.)
YES
NO
only in home communi CNITE
Attend disaster institutes, if
YES
NO
2. Serve in case
of disaster
In other communities
offered, in preparation for service
5. Assist with other chapter
3. Teach nurse's
YES
NO
4. Accept membership on chapter cóm-
YES
NO
YES
NO
aide classes
mittee should services be needed
programs, as needed
If you have not answered "Yes" to any of the questions listed under VOLUNTEER SERVICE, do you anticipate that
YES
NO
you will be able to serve at some time in the future?
IF UNABLE TO SERVE, GIVE MAJOR REASONS
DATE
SIGNATURE
august 8-1945:
Hellu Brown
YOUR VALUE AS A RED CROSS NURSE DEPENDS ON YOUR ABILITY AND WILLINGNESS TO SERVE AND YOUR FAITHPOLNESS IN
KEEPING US INFORMED OF YOUR ADDRESS. PLEASE FILL IN THIS QUESTIONWAIRE AND RETURN If PROMPTLY TO THE
COMMITTEE NAMED BELOW.
Fill in committee name and address before sending questionnaire to
nurse.
ATTENTION
SECRETARY
A.R.C. - N.R.
NURSE RECRUITMENT
COMMITTEE
muncie Chapter mume And
of
FORM 1045 Rev. July 1945
78504M
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Document data
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"ocrText": "B\nRED CROSS BADGE NUMBER\nAMERICAN RED CROSS\n7125\nNURSING SERVICES\n2\nMILITARY SERIAL NUMBER\nANNUAL QUESTIONNAIRE - 1945\nCHECK IF YOUR LAST NAME HAS CHANGED\nNAME (Last, first, middle)\nTELEPHONE NO.\nBrown Hellie Gates\n8098 muncie\nIF MARRIED, GIVE MAIDEN NAME\nHUSBAND'S NAME\nPERMANENT ADDRESS (Street, city, zone, county, state) Route 6- - muncie Indiana\nPRESENT ADDRESS (Street, city, zone, county, state)\n\"\nNAME AND ADDRESS OF NEAREST RELATIVE OR FRIEND IN THE UNITED STATES\nRELATIONSHIP\nMiss Lauia 8 Brown Route 6- Minnie Ind.\nsister\nDATE OF BIRTH (Month, day, year)\nSingle\nJuly 12- 1885\nMarried\nSeparated\nWidowed\nD1 vorced\nWHAT LANGUAGES DO YOU SPEAK?\nYES\nNO\nEnglish\nFrench\n(poo)\nHIGH SCHOOL GRADUATE\nNAME OF COLLEGE OR\nDEGREE OR\nUNIVERSITY ATTENDED\nLOCATION\nINCLUSIVE DATES\nDIPLOMA\nMAJOR\nTeachers College tolumbia n.y\n331927 Teaching Schools\n8 Tursing\nARE YOU CURRENTLY\nYES\nNO\nREGISTERED IN (State)\nARE YOU CURRENTLY A MEMBER OF THE AMERICAN\nYES\nNO\nIndiana\nNURSES' ASSOCIATION?\nC.\n4\nREGISTERED?\nPRESENT EMPLOYMENT If not employed, check\nPOSITION TITLE (H.N.; P.D., inst., staff nurse, etc.)\nSERVICE (Medicine surgery, etc.)\nSupt\nCITY\nIn\nNAME OF HOSPITAL OR ORGANIZATION BY WHOM EMPLOYED\nSTATE\nBAll Memoical Hospital Muncie\nn\nHEALTH\nIF OTHER THAN GOOD, SPECIFY NATURE AND ANTICIRATED DURATION OF DISABILITY\nTx\nGood.\ncillie\nVOLUNTEER SERVICE\nThe purpose of the following statements s to identify theynurses who can be counted upon to respond to a call\nto participate in a Red Cross chapter program please check the \"Xes\" box only if you are willing and able to\nserve if called on within the next 12 months.\nCo\ngive\nNAME AND ADDRESS OF THE CHAPTER IN WHOSE JURISDICTION YOU EXPECT TO LIVE FOR THE NEXT 12 MONTHS\nMinnese\nNO Attend an instructors' training program 1f offered. (Funds are available for\nChapter\n(E)\n94\nYES\nNO\n1. Teach home\nYES\nnursing classes\ntraining home nursing Instructors. See local chapter.)\nYES\nNO\nonly in home communi CNITE\nAttend disaster institutes, if\nYES\nNO\n2. Serve in case\nof disaster\nIn other communities\noffered, in preparation for service\n5. Assist with other chapter\n3. Teach nurse's\nYES\nNO\n4. Accept membership on chapter cóm-\nYES\nNO\nYES\nNO\naide classes\nmittee should services be needed\nprograms, as needed\nIf you have not answered \"Yes\" to any of the questions listed under VOLUNTEER SERVICE, do you anticipate that\nYES\nNO\nyou will be able to serve at some time in the future?\nIF UNABLE TO SERVE, GIVE MAJOR REASONS\nDATE\nSIGNATURE\naugust 8-1945:\nHellu Brown\nYOUR VALUE AS A RED CROSS NURSE DEPENDS ON YOUR ABILITY AND WILLINGNESS TO SERVE AND YOUR FAITHPOLNESS IN\nKEEPING US INFORMED OF YOUR ADDRESS. PLEASE FILL IN THIS QUESTIONWAIRE AND RETURN If PROMPTLY TO THE\nCOMMITTEE NAMED BELOW.\nFill in committee name and address before sending questionnaire to\nnurse.\nATTENTION\nSECRETARY\nA.R.C. - N.R.\nNURSE RECRUITMENT\nCOMMITTEE\nmuncie Chapter mume And\nof\nFORM 1045 Rev. July 1945\n78504M"
}