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B, H. 13
1/4/18
D. M.R.-1
THI
CROSS
ASHINGTON
NURSING SERVICE
APPLICATION FOR ENROLLMENT
(To be filled out entirely in applicant's handwriting and each question answered fully)
1. Name of applicant in full Scott.
2. Address in full, Street City Frankfort
State Indiana
32 4. 3. Are Date you of married, birth January single or a widow? widow, 21 1885 divorced Place Are of you birth a citizen Frankfort, of the United States? Indiana
5. Have you any physical defects or tendency to constitutional or pulmonary trouble? no
yee
Are you physically strong and healthy? yes
6. Name educational institutions attended before entering training school stating number of years at each and from which you
California Height School graduated none 1903-
were graduated. Frank orf grammer school
7. What languages other than English do you speak?
8. Occupation before entering training school none
ok
9. From City and what state hospital training school did you Illinois receive your diplo ma? Prestyterian Hoopital not
Chicago,
Date of graduation 30, 1907.
10.
Character of hospital: General? general Special?
Private?
11. 12. Did your training include obstetrics? yes Care of men? yes Children? hundredength Yes Contagious diseases? no
13. Name and address of superintendent of training school under whom you received Maining miss 3-yrs.
Daily average number of patients in hospitals during training of course mo-
m. millan 1750 W Congress St. Chicago, Illinois
14. If your training as a nurse was received in more than one/hospital, give name, location an time spent in each
15. Elgin what nursing Ill. organizations you member for the Insave months. member
are a
Treabyterian Hospital alumnie Association
of
16. Which, any, is affiliated with the American Nurses Association
17. Give name and address of secretary of at least one of these organizations
18. Are you a registered nurse? yes.
In what state? Illinois Date of registration July, 1960.
19. State how, where and for what period of time, in each instance, you have been employed since graduation, including present
employment, giving name and address of persons in charge
Special lintil nursing 10909- at married Preshyterian hospital after graduation
special nurcing Frankfort, Sept 1917 until
present
(Specify for which of the following services you wish to be considered.)
20.
War
service,
wherever needed Nas service S. only.
Are Instructor, willing Elementary take Hygiene the oath of allegiance? yes
you to
When available anytime
21.
Home Dietetics
Surgical Dressings
22. Public Health Nursing in Town and Country Nursing Service
23. Name and permanent address of nearest relative
Frankfort, Indiana
Charles Ham (father)
Date Jaw. 4-18
Signature Flina Ham Scott
To the Committee:
This blank is to be sent to applicant with circular letter D. M. R. 7, together with Forms D. M. R. 2, 11, and A. R. C. 150.
Application forms (except of a nurse desiring to enroll for the Town and Country Nursing Service) after approval and endorsement
by Local Committee, with credentials (Forms 3 and 4) together with Forms 10 and 11, should be forwarded to the Chairman,
National Committee on Nursing Service, American Red Cross, Washington, D.C.
In case the application forms of a nurse desiring to enroll for the Town and Country Nursing Service are sent to the Local
Committee, instead of to Washington, as instructed, such forms should be forwarded at once to Washington by the Local Com-
mittee, from whence credentials will be procured.
REQ. 17-876-May 20M
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Document data
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"ocrText": "B, H. 13\n1/4/18\nD. M.R.-1\nTHI\nCROSS\nASHINGTON\nNURSING SERVICE\nAPPLICATION FOR ENROLLMENT\n(To be filled out entirely in applicant's handwriting and each question answered fully)\n1. Name of applicant in full Scott.\n2. Address in full, Street City Frankfort\nState Indiana\n32 4. 3. Are Date you of married, birth January single or a widow? widow, 21 1885 divorced Place Are of you birth a citizen Frankfort, of the United States? Indiana\n5. Have you any physical defects or tendency to constitutional or pulmonary trouble? no\nyee\nAre you physically strong and healthy? yes\n6. Name educational institutions attended before entering training school stating number of years at each and from which you\nCalifornia Height School graduated none 1903-\nwere graduated. Frank orf grammer school\n7. What languages other than English do you speak?\n8. Occupation before entering training school none\nok\n9. From City and what state hospital training school did you Illinois receive your diplo ma? Prestyterian Hoopital not\nChicago,\nDate of graduation 30, 1907.\n10.\nCharacter of hospital: General? general Special?\nPrivate?\n11. 12. Did your training include obstetrics? yes Care of men? yes Children? hundredength Yes Contagious diseases? no\n13. Name and address of superintendent of training school under whom you received Maining miss 3-yrs.\nDaily average number of patients in hospitals during training of course mo-\nm. millan 1750 W Congress St. Chicago, Illinois\n14. If your training as a nurse was received in more than one/hospital, give name, location an time spent in each\n15. Elgin what nursing Ill. organizations you member for the Insave months. member\nare a\nTreabyterian Hospital alumnie Association\nof\n16. Which, any, is affiliated with the American Nurses Association\n17. Give name and address of secretary of at least one of these organizations\n18. Are you a registered nurse? yes.\nIn what state? Illinois Date of registration July, 1960.\n19. State how, where and for what period of time, in each instance, you have been employed since graduation, including present\nemployment, giving name and address of persons in charge\nSpecial lintil nursing 10909- at married Preshyterian hospital after graduation\nspecial nurcing Frankfort, Sept 1917 until\npresent\n(Specify for which of the following services you wish to be considered.)\n20.\nWar\nservice,\nwherever needed Nas service S. only.\nAre Instructor, willing Elementary take Hygiene the oath of allegiance? yes\nyou to\nWhen available anytime\n21.\nHome Dietetics\nSurgical Dressings\n22. Public Health Nursing in Town and Country Nursing Service\n23. Name and permanent address of nearest relative\nFrankfort, Indiana\nCharles Ham (father)\nDate Jaw. 4-18\nSignature Flina Ham Scott\nTo the Committee:\nThis blank is to be sent to applicant with circular letter D. M. R. 7, together with Forms D. M. R. 2, 11, and A. R. C. 150.\nApplication forms (except of a nurse desiring to enroll for the Town and Country Nursing Service) after approval and endorsement\nby Local Committee, with credentials (Forms 3 and 4) together with Forms 10 and 11, should be forwarded to the Chairman,\nNational Committee on Nursing Service, American Red Cross, Washington, D.C.\nIn case the application forms of a nurse desiring to enroll for the Town and Country Nursing Service are sent to the Local\nCommittee, instead of to Washington, as instructed, such forms should be forwarded at once to Washington by the Local Com-\nmittee, from whence credentials will be procured.\nREQ. 17-876-May 20M"
}