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ECENT
RED CROSS BADGE NUMBER
AMERICAN RED CROSS
5
16360
NURSING SERVICES
SEP 17 1945
MILITARY SERIAL NUMBER
ANNUAL QUESTIONNAIRE AMERA5, CROSS
CHECK IF YOUR LAST NAME HAS CHANGED
NAME (Last, first, middle)
Harriette Mild an Wanglas
Santa Monica . Ocean Park Chapter
TELEPHONE NO.
IF MARRIED, GIVE MAIDEN NAME
4-2604
HUSBAND'S NAME
PERMANENT ADDRESS (Street, city, zone, County, state)
PRESENT
ADDRESS 722-4m (Street, city, m zone, Lt. county, state) Santa Inamia. Calef
Same.
NAME AND ADDRESS OF NEAREST RELATIVE OR FRIEND IN THE UNITED STATES
RELATIONSHIP
DATE OF BIRTH year)
Alfred Has (Month, day, duing Gag 38 He nephent
August 10 18 75
Single
Married
Separated
Widowed-
Divorced
WHAT LANGUAGES DO YOU SPEAK?
French & English
YES
NO
next
HIGH SCHOOL GRADUATE Schools
NAME OF COLLEGE OR
DEGREE OR
UNIVERSITY ATTENDED
LOCATION
INCLUSIVE DATES
DIPLOMA
MAJOR
ARE YOU CURRENTLY
YES
NO
REGISTERED IN (State)
ARE YOU CURRENTLY A MEMBER OF THE AMERICAN
YES
NO
REGISTERED?
NURSES' ASSOCIATION?
PRESENT EMPLOYMENT If not employed, check
POSITION TITLE (H.N., P.D., inst., staff nurse, etc.)
SERVICE (Medicine, surgery, etc.)
NAME OF HOSPITAL OR ORGANIZATION BY WHOM EMPLOYED
CITY
STATE
HEALTH
Good
IF OTHER THAN GOOD, SPECIFY NATURE AND ANTICIPATED DURATION OF DISABILITY
VOLUNTEER SERVICE
The purpose of the following statements is to identify the nurses who can be counted upon to respond to a call
to participate in a Red Cross chapter program. Please check the "Yes" box only if you are willing and able to
serve if called on within the next 12 months.
NAME AND ADDRESS OF THE CHAPTER IN WHOSE JURISDICTION YOU EXPECT TO LIVE FOR THE NEXT 12 MONTHS
Sankw Monica Chapter 153 San Vicente Blvd. Santa Monica, calif.
1. Teach home
YES
NO
Attend an instructors' training program, if offered. (Funds are available for
YES
NO
nursing classes
training home nursing instructors. See local chapter.)
2. Serve in case
YES
NO
only in home community
Attend disaster institutes, 1f
YES
NO
of disaster
In other communities
offered, in preparation for service
3. Teach nurse's
YES
NO
4. Accept membership on chapter com-
YES
NO
5. Assist with other chapter
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
Sept. 17th 1945
Harriette SIGNATURE Dheldm Drug las
11/26/16
YOUR VALUE AS A RED CROSS NURSE DEPENDS ON YOUR ABILITY AND WILLINGNESS TO SERVE AND YOUR FWITHFULNESS IN
KEEPING US INFORMED OF YOUR ADDRESS. PLEASE FILL IN THIS QUESTIONNAIRE AND RETURN IT PROMPTLY TO THE
COMMITTEE NAMED BELOW.
ATTENTION
Fill in committee name and address before sending questionnaire to nurse.
SECRETARY
Nurse Recruitment Committee
NURSE RECRUITMENT
Santa Monica Chapter A. R. C.
COMMITTEE
153 San Vicente Blvd., Santa Monica, Calif.
78504M
FORM 1045 Rev. July 1945
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"ocrText": "ECENT\nRED CROSS BADGE NUMBER\nAMERICAN RED CROSS\n5\n16360\nNURSING SERVICES\nSEP 17 1945\nMILITARY SERIAL NUMBER\nANNUAL QUESTIONNAIRE AMERA5, CROSS\nCHECK IF YOUR LAST NAME HAS CHANGED\nNAME (Last, first, middle)\nHarriette Mild an Wanglas\nSanta Monica . Ocean Park Chapter\nTELEPHONE NO.\nIF MARRIED, GIVE MAIDEN NAME\n4-2604\nHUSBAND'S NAME\nPERMANENT ADDRESS (Street, city, zone, County, state)\nPRESENT\nADDRESS 722-4m (Street, city, m zone, Lt. county, state) Santa Inamia. Calef\nSame.\nNAME AND ADDRESS OF NEAREST RELATIVE OR FRIEND IN THE UNITED STATES\nRELATIONSHIP\nDATE OF BIRTH year)\nAlfred Has (Month, day, duing Gag 38 He nephent\nAugust 10 18 75\nSingle\nMarried\nSeparated\nWidowed-\nDivorced\nWHAT LANGUAGES DO YOU SPEAK?\nFrench & English\nYES\nNO\nnext\nHIGH SCHOOL GRADUATE Schools\nNAME OF COLLEGE OR\nDEGREE OR\nUNIVERSITY ATTENDED\nLOCATION\nINCLUSIVE DATES\nDIPLOMA\nMAJOR\nARE YOU CURRENTLY\nYES\nNO\nREGISTERED IN (State)\nARE YOU CURRENTLY A MEMBER OF THE AMERICAN\nYES\nNO\nREGISTERED?\nNURSES' ASSOCIATION?\nPRESENT EMPLOYMENT If not employed, check\nPOSITION TITLE (H.N., P.D., inst., staff nurse, etc.)\nSERVICE (Medicine, surgery, etc.)\nNAME OF HOSPITAL OR ORGANIZATION BY WHOM EMPLOYED\nCITY\nSTATE\nHEALTH\nGood\nIF OTHER THAN GOOD, SPECIFY NATURE AND ANTICIPATED DURATION OF DISABILITY\nVOLUNTEER SERVICE\nThe purpose of the following statements is to identify the nurses who can be counted upon to respond to a call\nto participate in a Red Cross chapter program. Please check the \"Yes\" box only if you are willing and able to\nserve if called on within the next 12 months.\nNAME AND ADDRESS OF THE CHAPTER IN WHOSE JURISDICTION YOU EXPECT TO LIVE FOR THE NEXT 12 MONTHS\nSankw Monica Chapter 153 San Vicente Blvd. Santa Monica, calif.\n1. Teach home\nYES\nNO\nAttend an instructors' training program, if offered. (Funds are available for\nYES\nNO\nnursing classes\ntraining home nursing instructors. See local chapter.)\n2. Serve in case\nYES\nNO\nonly in home community\nAttend disaster institutes, 1f\nYES\nNO\nof disaster\nIn other communities\noffered, in preparation for service\n3. Teach nurse's\nYES\nNO\n4. Accept membership on chapter com-\nYES\nNO\n5. Assist with other chapter\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?\n(\nIF UNABLE TO SERVE, GIVE MAJOR REASONS.\nDATE\nSept. 17th 1945\nHarriette SIGNATURE Dheldm Drug las\n11/26/16\nYOUR VALUE AS A RED CROSS NURSE DEPENDS ON YOUR ABILITY AND WILLINGNESS TO SERVE AND YOUR FWITHFULNESS IN\nKEEPING US INFORMED OF YOUR ADDRESS. PLEASE FILL IN THIS QUESTIONNAIRE AND RETURN IT PROMPTLY TO THE\nCOMMITTEE NAMED BELOW.\nATTENTION\nFill in committee name and address before sending questionnaire to nurse.\nSECRETARY\nNurse Recruitment Committee\nNURSE RECRUITMENT\nSanta Monica Chapter A. R. C.\nCOMMITTEE\n153 San Vicente Blvd., Santa Monica, Calif.\n78504M\nFORM 1045 Rev. July 1945"
}