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FORM 1045
REV. 1-2-35
THE AMERICAN RED CROSS
M
NATIONAL HEADQUARTERS
WASHINGTON, D. c.
H
Dear Madam:
The National Committee on Red Cross Nursing Service requires us to submit,
annually, a report of all the Red Cross Nurses enrolled with our Committee. Will you
therefore, please answer the following questions and return this form to me, in the
enclosed envelope, at the earliest possible date? THIS ANNUAL QUESTIONNAIRE IS FILED
WITH YOUR RECORDS AT NATIONAL HEADQUARTERS IN WASHINGTON, D. C. We hope you will rec-
ognize the value of filing this information and will return the questionnaire promptly,
as we are extremely anxious to make a very complete report to National Headquarters.
IMPORTANT:
Yours sincerely,
In order to render prompt service
in time of disaster, enrolled Red Cross
HELEN STEPHEN
Chairman or
STREET
Secretary.
Nurses should report at once to the
Secretary of the Local Committee under
ORANGE,
-
N.J.
Local Committee.
which they are enrolled. Do not forget
the address of the Secretary.
Name in full
Marie I Camebbell
If married, give husband's name
Permanent
address P.O.Box18
Illiddlebury NEW Hancu
Coure
(STREET, ETC.)
(CITY)
(COUNTY)
(STATE)
Probable address for the next year
Drange Memorial Nospital
(STREET, ETC.)
Telephone No. Dr. 10,00
Drange Essex New Jersey
(CITY)
(COUNTY)
(STATE)
Name and address of nearest relative or friend, in United States, through whom you may
be communicated with in an emergency. (State relationship)
Digues a Riualdi (sister) 0.0 Bax 18 Widdlebury Pours
Underline the type of work you are now doing:
Army - Navy - U.S.P.H. Service - Veterans Administration - U.S. Indian Service -
W
Public Health - Institutional - Private Duty - Industrial - Office Nurse - Registrar.
5,
Are you an instructor of Red Cross classes in Home Hygiene and Care of the Sick? No
Have you ever been? No
Indicate present physical condition Good
8
Would you respond to an emergency call in event of epidemic, disaster, war, etc. ? yes
6
Badge No. 35586
Current date March 26 be 1937
NOTE. If the nurse does not complete and return this questionnaire, and can not be
located within two years, her enrolment will be removed from our active files.
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"ocrText": "FORM 1045\nREV. 1-2-35\nTHE AMERICAN RED CROSS\nM\nNATIONAL HEADQUARTERS\nWASHINGTON, D. c.\nH\nDear Madam:\nThe National Committee on Red Cross Nursing Service requires us to submit,\nannually, a report of all the Red Cross Nurses enrolled with our Committee. Will you\ntherefore, please answer the following questions and return this form to me, in the\nenclosed envelope, at the earliest possible date? THIS ANNUAL QUESTIONNAIRE IS FILED\nWITH YOUR RECORDS AT NATIONAL HEADQUARTERS IN WASHINGTON, D. C. We hope you will rec-\nognize the value of filing this information and will return the questionnaire promptly,\nas we are extremely anxious to make a very complete report to National Headquarters.\nIMPORTANT:\nYours sincerely,\nIn order to render prompt service\nin time of disaster, enrolled Red Cross\nHELEN STEPHEN\nChairman or\nSTREET\nSecretary.\nNurses should report at once to the\nSecretary of the Local Committee under\nORANGE,\n-\nN.J.\nLocal Committee.\nwhich they are enrolled. Do not forget\nthe address of the Secretary.\nName in full\nMarie I Camebbell\nIf married, give husband's name\nPermanent\naddress P.O.Box18\nIlliddlebury NEW Hancu\nCoure\n(STREET, ETC.)\n(CITY)\n(COUNTY)\n(STATE)\nProbable address for the next year\nDrange Memorial Nospital\n(STREET, ETC.)\nTelephone No. Dr. 10,00\nDrange Essex New Jersey\n(CITY)\n(COUNTY)\n(STATE)\nName and address of nearest relative or friend, in United States, through whom you may\nbe communicated with in an emergency. (State relationship)\nDigues a Riualdi (sister) 0.0 Bax 18 Widdlebury Pours\nUnderline the type of work you are now doing:\nArmy - Navy - U.S.P.H. Service - Veterans Administration - U.S. Indian Service -\nW\nPublic Health - Institutional - Private Duty - Industrial - Office Nurse - Registrar.\n5,\nAre you an instructor of Red Cross classes in Home Hygiene and Care of the Sick? No\nHave you ever been? No\nIndicate present physical condition Good\n8\nWould you respond to an emergency call in event of epidemic, disaster, war, etc. ? yes\n6\nBadge No. 35586\nCurrent date March 26 be 1937\nNOTE. If the nurse does not complete and return this questionnaire, and can not be\nlocated within two years, her enrolment will be removed from our active files."
}