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Form 1037
Rev. May, 1939
THE AMERICAN RED CROSS NURSING SERVICE
APPLICATION FOR ENROLLMENT
(To be filled out/in applicant's handwriting and each question answered fully)
31
1. Name of
applicant in full Date of birth: Feb 11, 1909 (Month) (Day) (Year)
J.
Permanent address 57 Grave Street, Moulclair
If married, give maiden name
2.
notsferry
Probable address for one year 57 (Street) grove st. (City) Miriclair
(State) (State) n.J.
(b
3. Race white Place of birth Nova (Street) Scalia Canadititisal (City) status single
(single, married widowed or divorced)
Birthplace of father Nova Scatian Mother Nova Scates litizenship of father Canadian
Are you a citizen of the United States? yes, Naturalized. No. of 1940 Did
years
you graduate?
4. GENERAL EDUCATION (prior to entering nursing) :
attendance
Yes or No
High School
4
yes
Normal school
......
-
n/
-
College or University
id is
or
Other
What languages other than English do you speak?
none
(Underline those which you speak fluently)
5. PROFESSIONAL EDUCATION
a. School of Nursing from which you graduated:
Mountaniside Hospital
Moulclair (City) new (State) Jersey
VILE
AOR
(Name)
CLOZE
Date
of graduation May 1939 general
Length of course. 2 9 months
Daily Average
years
Character of hospital Generalor special
No. of patients
1u
during training
&
250
In this hospital, which services did you receive experience in as segregated services (underline) :
Eye, Ear Communicable
Outpatient
Medicine- Surgery - -Pediatrics-Obstetrics- Nose & Throat- - Diseases- - Psychiatry - Department
In this hospital, which services did you receive experience in as non-segregated services (underline) :
Eye, Ear
Communicable
Outpatient
Medicine-Surgery-Pediatrics-Obstetrics-Nose - & Throat Diseases - Psychiatry - Department
b. Undergraduate affiliations:
Clinical
Hospital or Organization
City and State
specialty
No. months
(1) Willand Parker newyork ny Communicable i seases
3
mos.
(2)
(3)
c. Postgraduate clinical or field courses (Do not include academic work).
Clinical
Hospital or Organization
City and State
specialty
No. months
(1) (2) / year Silving new Room Jensey Mountewside Hospital-
8
(3)
U
d. Academic study since graduation from Nursing School.
College or University
City and State
Nature of work
No. months
(1) none
(2)
none
a
(3)
none
&
(OVER)
Page data
- Page
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- Source index
- 0
- Type
- photo
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- e33a345902a6f4e9
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Document data
- ID
- 2661862
- Core
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- Type
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"ocrText": "t\nM\na\nFi\nC\ned\nI\n0\nF\nForm 1037\nRev. May, 1939\nTHE AMERICAN RED CROSS NURSING SERVICE\nAPPLICATION FOR ENROLLMENT\n(To be filled out/in applicant's handwriting and each question answered fully)\n31\n1. Name of\napplicant in full Date of birth: Feb 11, 1909 (Month) (Day) (Year)\nJ.\nPermanent address 57 Grave Street, Moulclair\nIf married, give maiden name\n2.\nnotsferry\nProbable address for one year 57 (Street) grove st. (City) Miriclair\n(State) (State) n.J.\n(b\n3. Race white Place of birth Nova (Street) Scalia Canadititisal (City) status single\n(single, married widowed or divorced)\nBirthplace of father Nova Scatian Mother Nova Scates litizenship of father Canadian\nAre you a citizen of the United States? yes, Naturalized. No. of 1940 Did\nyears\nyou graduate?\n4. GENERAL EDUCATION (prior to entering nursing) :\nattendance\nYes or No\nHigh School\n4\nyes\nNormal school\n......\n-\nn/\n-\nCollege or University\nid is\nor\nOther\nWhat languages other than English do you speak?\nnone\n(Underline those which you speak fluently)\n5. PROFESSIONAL EDUCATION\na. School of Nursing from which you graduated:\nMountaniside Hospital\nMoulclair (City) new (State) Jersey\nVILE\nAOR\n(Name)\nCLOZE\nDate\nof graduation May 1939 general\nLength of course. 2 9 months\nDaily Average\nyears\nCharacter of hospital Generalor special\nNo. of patients\n1u\nduring training\n&\n250\nIn this hospital, which services did you receive experience in as segregated services (underline) :\nEye, Ear Communicable\nOutpatient\nMedicine- Surgery - -Pediatrics-Obstetrics- Nose & Throat- - Diseases- - Psychiatry - Department\nIn this hospital, which services did you receive experience in as non-segregated services (underline) :\nEye, Ear\nCommunicable\nOutpatient\nMedicine-Surgery-Pediatrics-Obstetrics-Nose - & Throat Diseases - Psychiatry - Department\nb. Undergraduate affiliations:\nClinical\nHospital or Organization\nCity and State\nspecialty\nNo. months\n(1) Willand Parker newyork ny Communicable i seases\n3\nmos.\n(2)\n(3)\nc. Postgraduate clinical or field courses (Do not include academic work).\nClinical\nHospital or Organization\nCity and State\nspecialty\nNo. months\n(1) (2) / year Silving new Room Jensey Mountewside Hospital-\n8\n(3)\nU\nd. Academic study since graduation from Nursing School.\nCollege or University\nCity and State\nNature of work\nNo. months\n(1) none\n(2)\nnone\na\n(3)\nnone\n&\n(OVER)"
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