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Form 1037
THE AMERICAN NATIONAL RED CROSS NURSING SERVICE
Rev. 4-15-30
Application for Enrollment
(To be filled out entirely in applicant's handwriting and each question answered fully.)
1.
Name
of
applicant
in
full
2.
Greeners 56 Lucretia Place Portland-oncy
deprestic
Permanent address in full
Probable address for one year
11
11
H
34
3.
Date of birth nov 16-1900 Race White
Place of birth Paris - France
Birthplace of father (Month) nice. (Day) (Year) Mother Paris -France Citizenship of father T.S. eve when
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? 7- High school? 2 Normal school?
Private school? 2
College?
If tutored privately, name subjects covered and length of
time
6. What languages other than English do you speak French Italian
(Underline those which you speak fluently)
7. Occupation before entering training school French teacher.
8. From what hospital training school did you receive your diploma ? St rincent's Hosp.
City and State PorTTand. - one Date of graduation June 15th in 1931.
Give name at time
of graduation Generieve Represtice
9. Character of Hospital : General? Gen
Special?
Private?
10. Did your training include obstetrics? yes Care of men? yes Children? Contagious diseases? YES
11. Daily average number of patients in hospital during training 450 Length of course 3 yrs-
12. Name and address of superintendent of nurses under whom you received training Sister
Geneviere - Mt. St rincent Hospital Seattle - wash
13. If your training as a nurse was received in more than one hospital, give name, location and time spent in
each two years and ripemonths at St. Vincents - 3 months at the Doernbecker
14. Are you a member of your Alumnae Association? YES
15. Are you affiliated with the American Nurses' Association through membership in Alumnae, District 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 the District or State Association of which you are a member.
Ellah moore -
67
673 Johnson St. Portland ore-
17. Are you a registered nurse? YES In what State? ore Date of registration Feb. 12 Number 3562.
1932
18. Type of work and length of service since graduation:
special nurse-
(Present position)
special
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; Instruc-
tor, 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 March 12th
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 (state rela-
tionship)
Rene (Father), Leprestre Esq; white oaks Gosher N.Y.
Date
march
7 hi
Signature
of
nurse
Gruevier
NOTE-Nurses who have had training or experience in Public Health Nursing will, in addition to the above, fill out questions 23
apristre
and 24 on reverse side of this blank.
To the Local Committee:
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. 4-15-30\nApplication for Enrollment\n(To be filled out entirely in applicant's handwriting and each question answered fully.)\n1.\nName\nof\napplicant\nin\nfull\n2.\nGreeners 56 Lucretia Place Portland-oncy\ndeprestic\nPermanent address in full\nProbable address for one year\n11\n11\nH\n34\n3.\nDate of birth nov 16-1900 Race White\nPlace of birth Paris - France\nBirthplace of father (Month) nice. (Day) (Year) Mother Paris -France Citizenship of father T.S. eve when\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? 7- High school? 2 Normal school?\nPrivate school? 2\nCollege?\nIf tutored privately, name subjects covered and length of\ntime\n6. What languages other than English do you speak French Italian\n(Underline those which you speak fluently)\n7. Occupation before entering training school French teacher.\n8. From what hospital training school did you receive your diploma ? St rincent's Hosp.\nCity and State PorTTand. - one Date of graduation June 15th in 1931.\nGive name at time\nof graduation Generieve Represtice\n9. Character of Hospital : General? Gen\nSpecial?\nPrivate?\n10. Did your training include obstetrics? yes Care of men? yes Children? Contagious diseases? YES\n11. Daily average number of patients in hospital during training 450 Length of course 3 yrs-\n12. Name and address of superintendent of nurses under whom you received training Sister\nGeneviere - Mt. St rincent Hospital Seattle - wash\n13. If your training as a nurse was received in more than one hospital, give name, location and time spent in\neach two years and ripemonths at St. Vincents - 3 months at the Doernbecker\n14. Are you a member of your Alumnae Association? YES\n15. Are you affiliated with the American Nurses' Association through membership in Alumnae, District and\nState Associations? YES\nAffiliation with the American Nurses' Association means membership in the District and Graduate Nurses' Associations of the state\nin which you are living at the present time.\n16.\nGive name and address of secretary of the District or State Association of which you are a member.\nEllah moore -\n67\n673 Johnson St. Portland ore-\n17. Are you a registered nurse? YES In what State? ore Date of registration Feb. 12 Number 3562.\n1932\n18. Type of work and length of service since graduation:\nspecial nurse-\n(Present position)\nspecial\n19. Will 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; Instruc-\ntor, Home Hygiene and Care of Sick Army; Navy U. S. Public Health Service; U. S. Veterans\nBureau.\n(b) Date upon which you will be available for service checked March 12th\n21. Are you willing to take the oath of allegiance? YES\n22. Give name and permanent address of nearest relative or friend, residing in the United States (state rela-\ntionship)\nRene (Father), Leprestre Esq; white oaks Gosher N.Y.\nDate\nmarch\n7 hi\nSignature\nof\nnurse\nGruevier\nNOTE-Nurses who have had training or experience in Public Health Nursing will, in addition to the above, fill out questions 23\napristre\nand 24 on reverse side of this blank.\nTo the Local Committee:\nThis blank is to be sent to applicant with circular letter Form 1199, together with Forms 2, 1193 and A. R. C. 703.\nApplication forms after approval and endorsement by Local Committee, with Forms 1244, 1189, and 1193 should be\nforwarded to National Headquarters or to the proper Branch Office.\n(OVER)"
}