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Form 1037
THE AMERICAN NATIONAL RED CROSS NURSING SERVICE
Rev. 2-15-28
Application for Enrollment
mabel Countr soh ered.)
E
(To be filled out entirely in applicant's handwriting and each question answered fully.)
d
1.
Name of applicant in full Ednz m care
Colobauoh, New Hampshine
2. Present Address in full address - Strong minneal Harfital Roclustry 44,
3. Date of birth Ang.14,1907
Race Cunczsian Place of birth Colebnuch. N.H
6
2
Birthplace of father Coloback N.H. Mother Colebruhan If Gitizenship of father American
4. Are you married, single or a widow ? Single Are you a citizen of the United States yes
5. How many years have you attended Grammar school ? 8 High school ? 4 Normal school ? Summon
school
Mike
M
Private school ?
College ? If tutored privately, name subjects covered and length of time
6. What languages other than English do you speak ?
none
(Underline those which you speak fluently)
7. Occupation before entering training school Teacher public school
8.
From what hospital training school did you receive your diploma ? muss general Hospital
City and State Boalon, Mess
Date of graduation
1928
Give name at time of graduation
same
9.
Character of Hospital: General ? yes Special ?
Private?
10. Did your training include obstetrics ? Y's Care of men ?yrs Children yes Contagious diseases No
11. Daily average number of patients in hospital during training
Length of course 3
12. Name and address of superintendent of nurses under whom you received training
Miss Sally Johnson Moss general Hospital, Boston Mass
13. If your training as a nurse was received in more than one hospital, give name, location and time
spent in each
14. Are you a member of your Alumnae Association yes
15. Are you affiliated with the American Nurses Association through membership in Alumnae, Dis-
trict and State Associations
yes
Affiliation with the American Nurses' Association means membership in the District and Graduate Nurses' Associations of the
state in which you are living at the present time.
16. Give name and address of secretary of at least one of these organizations
Ruth Schnoma. 164 An Hony SY, Bechaston, NY. Sec. Valley Number Accoristion.
17. Are you a registered nurse ?yes In whate State ? N.Y. Date of registration 1938-3)Number 11387
18. Type of work and length of service since 'graduation:
Head Name-Midical - Mass. general Hospital, Boston Mass - 1year
Teaching Supervison Beth Isaan Hospital Bustn Mass - 14032
Sungical Supervisor Stang Memorial Hospital, Rockstear N.Y - 3yrans -
(Present position)
Sungical Supervisor- Starm Memorial Hospital -
19.
Will you be willing to accept service if the United States becomes involved in war yes
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.
=
(b) Date upon which you will be available for service checked
1934
5
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
8146
(state relationship)
Mn Frenh Call, Colebaooh N.4. (Father
Date 3/13/31
Signature of nurse
Edra m Cuss
NOTE-Nurses who have had training or experience in Public Health Nursing will, in addition to the above, fill out questions
23 and 24 on reverse side of this blank.
To The Local Committee: OI. arase
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": "Form 1037\nTHE AMERICAN NATIONAL RED CROSS NURSING SERVICE\nRev. 2-15-28\nApplication for Enrollment\nmabel Countr soh ered.)\nE\n(To be filled out entirely in applicant's handwriting and each question answered fully.)\nd\n1.\nName of applicant in full Ednz m care\nColobauoh, New Hampshine\n2. Present Address in full address - Strong minneal Harfital Roclustry 44,\n3. Date of birth Ang.14,1907\nRace Cunczsian Place of birth Colebnuch. N.H\n6\n2\nBirthplace of father Coloback N.H. Mother Colebruhan If Gitizenship of father American\n4. Are you married, single or a widow ? Single Are you a citizen of the United States yes\n5. How many years have you attended Grammar school ? 8 High school ? 4 Normal school ? Summon\nschool\nMike\nM\nPrivate school ?\nCollege ? If tutored privately, name subjects covered and length of time\n6. What languages other than English do you speak ?\nnone\n(Underline those which you speak fluently)\n7. Occupation before entering training school Teacher public school\n8.\nFrom what hospital training school did you receive your diploma ? muss general Hospital\nCity and State Boalon, Mess\nDate of graduation\n1928\nGive name at time of graduation\nsame\n9.\nCharacter of Hospital: General ? yes Special ?\nPrivate?\n10. Did your training include obstetrics ? Y's Care of men ?yrs Children yes Contagious diseases No\n11. Daily average number of patients in hospital during training\nLength of course 3\n12. Name and address of superintendent of nurses under whom you received training\nMiss Sally Johnson Moss general Hospital, Boston Mass\n13. If your training as a nurse was received in more than one hospital, give name, location and time\nspent in each\n14. Are you a member of your Alumnae Association yes\n15. Are you affiliated with the American Nurses Association through membership in Alumnae, Dis-\ntrict and State Associations\nyes\nAffiliation with the American Nurses' Association means membership in the District and Graduate Nurses' Associations of the\nstate in which you are living at the present time.\n16. Give name and address of secretary of at least one of these organizations\nRuth Schnoma. 164 An Hony SY, Bechaston, NY. Sec. Valley Number Accoristion.\n17. Are you a registered nurse ?yes In whate State ? N.Y. Date of registration 1938-3)Number 11387\n18. Type of work and length of service since 'graduation:\nHead Name-Midical - Mass. general Hospital, Boston Mass - 1year\nTeaching Supervison Beth Isaan Hospital Bustn Mass - 14032\nSungical Supervisor Stang Memorial Hospital, Rockstear N.Y - 3yrans -\n(Present position)\nSungical Supervisor- Starm Memorial Hospital -\n19.\nWill you be willing to accept service if the United States becomes involved in war yes\n20. (a) If interested in accepting service within the near future, indicate choice; R.C.P.H. Nursing,\nInstructor, Home Hygiene and care of Sick, Army, Navy, U. S. Public Health Service, U.\nS. Veterans' Bureau.\n=\n(b) Date upon which you will be available for service checked\n1934\n5\n21. Are you willing to take the oath of allegiance?\nyes\n22. Give name and permanent address of nearest relative or friend, residing in the United States\n8146\n(state relationship)\nMn Frenh Call, Colebaooh N.4. (Father\nDate 3/13/31\nSignature of nurse\nEdra m Cuss\nNOTE-Nurses who have had training or experience in Public Health Nursing will, in addition to the above, fill out questions\n23 and 24 on reverse side of this blank.\nTo The Local Committee: OI. arase\nThis blank is to be sent to applicant with circular letter Form 1199, together with Forms 2. 1193 and A.R.\nC.\n703. Application forms after approval and endorsement by Local Committee, with Forms 1244, 1189, and\n1193 should be forwarded to National Headquarters or to the proper Branch Office.\n(OVER)"
}