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D.M.R.-I
4
AMERICAN Ren CROSS
(CROIX-ROUGE AMÉRICAINE)
ÉLYSÉES 43-82
ADRESSE TÉLÉGRAPHIQUE :
43-83
"
TÉLÉPHONE
AMCROSS "
43-88
43-89
4, PLACE DE LA CONCORDE
NURSING SERVICE
st
PARIS,
now
APPLICATION FOR ENROLLMENT
(To be filled out entirely in applicant's handwriting and each question answered fully)
C
1.
Name
of
2. Address in full, Street YS-me Pitrarque City Paris
applicant \in full Frances No Sackel - Buckley.
State France
46 3. Date of birth Jan. 26. 1871
Place of birth Cape Umbint n.y.
4. Are you married, single or a widow ? single
5. Have you any physical defects or tendency to constitutional or pulmonary trouble ? no.
Are you a citizen of the United States ? yes
Are you physically strong and healthy ? yes
S
6.
Name educational institutions attended before entering training school, stating number of years at each and from which you were graduated
a
Cape U maine - High School.
p
7. What languages other than English do you speak P French.
T
8. Occupation before entering training school assisted my fasher who was C.U.
e
a
9. From what hospital training school did you receive your diploma ? se-7 whes Hospital, Wits u.y.
+
O,R. City and state miss, new york
Date
of
graduation aet 1897
10. Character of hospital : General ? yes
Special ?
Private ?
11. Did your training include obstetrics ? yes
Care of men ? yes
12. Daily average number of patients in hospitals during training 60
Children ? yes Length Contagious of course In diseases years ? yes
13. Name and address of superintendent of training school under whom you received training
ma Charles n. Crispell Emma I Keith-) Shellin Island Heights, n y
14. If your training as a nurse was received in more than one hospital, give name, location and time spent in each
O.K
15. OF what nursing organizations are you a member ? application made to allumai association,
16. St. Which, Inhis if any, is affiliated Hosp, with the mich, American Nurses Wy Association ? allanni amo (Ulia) el-Lules Hosp
17. Give name and address of secretary of at least one of these organizations
18. Are you a registered nurse ? yes
In what state ? New york
Date of registration
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 Privale- work in newyork state-for six years.
Privile - work n.i. Paris lew years Two years as - American ambulance
nevilly - sur Seim Three monts under american Rid Cross n. referingry
work in 7
(Specify for which of the following services you wish to be considered.)
20. War service, wherever needed
U. S. only
When available France
Are you willing to take the oath of allegiance P.
21. Instructor, Elementary Hygiene
Home Dietetics
Surgical Dressings
22. Public Health Nursing in Town and Country Nursing Service
23. Name and permanent address of nearest relative mn. gemmi 13. W anson,
Cape v mained 1 my
6
Signature Franses Sachel- Bushley
To the Committee :
8
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.
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"ocrText": "D.M.R.-I\n4\nAMERICAN Ren CROSS\n(CROIX-ROUGE AMÉRICAINE)\nÉLYSÉES 43-82\nADRESSE TÉLÉGRAPHIQUE :\n43-83\n\"\nTÉLÉPHONE\nAMCROSS \"\n43-88\n43-89\n4, PLACE DE LA CONCORDE\nNURSING SERVICE\nst\nPARIS,\nnow\nAPPLICATION FOR ENROLLMENT\n(To be filled out entirely in applicant's handwriting and each question answered fully)\nC\n1.\nName\nof\n2. Address in full, Street YS-me Pitrarque City Paris\napplicant \\in full Frances No Sackel - Buckley.\nState France\n46 3. Date of birth Jan. 26. 1871\nPlace of birth Cape Umbint n.y.\n4. Are you married, single or a widow ? single\n5. Have you any physical defects or tendency to constitutional or pulmonary trouble ? no.\nAre you a citizen of the United States ? yes\nAre you physically strong and healthy ? yes\nS\n6.\nName educational institutions attended before entering training school, stating number of years at each and from which you were graduated\na\nCape U maine - High School.\np\n7. What languages other than English do you speak P French.\nT\n8. Occupation before entering training school assisted my fasher who was C.U.\ne\na\n9. From what hospital training school did you receive your diploma ? se-7 whes Hospital, Wits u.y.\n+\nO,R. City and state miss, new york\nDate\nof\ngraduation aet 1897\n10. Character of hospital : General ? yes\nSpecial ?\nPrivate ?\n11. Did your training include obstetrics ? yes\nCare of men ? yes\n12. Daily average number of patients in hospitals during training 60\nChildren ? yes Length Contagious of course In diseases years ? yes\n13. Name and address of superintendent of training school under whom you received training\nma Charles n. Crispell Emma I Keith-) Shellin Island Heights, n y\n14. If your training as a nurse was received in more than one hospital, give name, location and time spent in each\nO.K\n15. OF what nursing organizations are you a member ? application made to allumai association,\n16. St. Which, Inhis if any, is affiliated Hosp, with the mich, American Nurses Wy Association ? allanni amo (Ulia) el-Lules Hosp\n17. Give name and address of secretary of at least one of these organizations\n18. Are you a registered nurse ? yes\nIn what state ? New york\nDate of registration\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 Privale- work in newyork state-for six years.\nPrivile - work n.i. Paris lew years Two years as - American ambulance\nnevilly - sur Seim Three monts under american Rid Cross n. referingry\nwork in 7\n(Specify for which of the following services you wish to be considered.)\n20. War service, wherever needed\nU. S. only\nWhen available France\nAre you willing to take the oath of allegiance P.\n21. Instructor, Elementary Hygiene\nHome Dietetics\nSurgical Dressings\n22. Public Health Nursing in Town and Country Nursing Service\n23. Name and permanent address of nearest relative mn. gemmi 13. W anson,\nCape v mained 1 my\n6\nSignature Franses Sachel- Bushley\nTo the Committee :\n8\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-\n-\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."
}