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RED CROSS BADGE NUMBER
AMERICAN RED CROSS
NURSING SERVICES
17806
AUG 2 1 1945
MILITARY SERIAL NUMBER
ANNUAL QUESTIONNAIRE - 1945
CHECK IF YOUR LAST NAME HAS CHANGED
NAME (Last, first, middle)
IF MARRIED,
Scott GIVE MAIDEN AlMA NAME H. (MRS)
TELEPHONE NO.
Curtis 8205
HUSBAND'S NAME
PERMANENT ADDRESS (Street, city, zone, county, state)
PRESENT ADDRESS (Street, city, zone, county, state)
1790 BRoad may, new York
1790 BRoadway , new york
NAME AND ADDRESS OF NEAREST RELATIVE OR FRIEND IN THE UNITED STATES
RELATIONSHIP
Jan. 21, 1885
DATE MRS OF Evelyn BIRTH (Month, Daugherty day, year) 359S. ackson St., Frankfort, Ind.
sister
Single
Married
Separated
Widowed
Divorced
WHAT LANGUAGES DO YOU SPEAK?
English
YES
NO
HIGH SCHOOL GRADUATE
NAME OF COLLEGE OR
DEGREE OR
UNIVERSITY ATTENDED
LOCATION
INCLUSIVE DATES
DIPLOMA
MAJOR
Teachers College
P.H.Organyphan
Columbia University NewYork N.Y.
(iffling 15 / points for
ARE YOU CURRENTLY
YES
NO
REGISTERED IN (State)
BS. Degree)
ARE YOU CURRENTLY A MEMBER OF THE AMERICAN
YES
NO
REGISTERED?
newylosk
NURSES' ASSOCIATION?
x
PRESENT EMPLOYMENT If not employed, check
POSITION TITLE (H.N., P.D. inst., staff nurse, etc.)
SERVICE (Medicine, surgery, etc.)
Executive Secretary
NAME OF HOSPITAL OR ORGANIZATION BY WHOM EMPLOYED
CITY
STATE
HEALTH American nurser Association
newyork,
U.Y-
IF OTHER THAN GOOD, SPECIFY NATURE AND ANTICIPATED DURATION OF DISABILITY
good 1
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
1. Teach home
YES
NO
Attend an instructors' training program, 11 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, if
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.
YOUR DATE Janish VALUE AS A RED CROSS 20, NURSE 1945
SIGNATURE the / Scort
DEPENDS ON YOUR ABILITY AND WILLINGNESS TO SERVE AND YOUR FAITHPULNESS IN
KEERING US INFORMED OF YOUR ADDRESS. PLEASE FILL IN THIS QUESTIONNAIRE AND RETURN IT PROMPTLY TO THE
Nurs ditment Committee
COMMITTEE NAMED BELOW.
ATTENTION
Neesau County Chapter
Fill in committee name and address before sending questionnaire to nurse.
SECRETARY
AMERICAN RED CROSS
NURSE RECRUITMENT
264 Old Country Road
COMMITTEE
Mineola, N. I!
78504M
FORM 1045 Rev. July 1945
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"ocrText": "RED CROSS BADGE NUMBER\nAMERICAN RED CROSS\nNURSING SERVICES\n17806\nAUG 2 1 1945\nMILITARY SERIAL NUMBER\nANNUAL QUESTIONNAIRE - 1945\nCHECK IF YOUR LAST NAME HAS CHANGED\nNAME (Last, first, middle)\nIF MARRIED,\nScott GIVE MAIDEN AlMA NAME H. (MRS)\nTELEPHONE NO.\nCurtis 8205\nHUSBAND'S NAME\nPERMANENT ADDRESS (Street, city, zone, county, state)\nPRESENT ADDRESS (Street, city, zone, county, state)\n1790 BRoad may, new York\n1790 BRoadway , new york\nNAME AND ADDRESS OF NEAREST RELATIVE OR FRIEND IN THE UNITED STATES\nRELATIONSHIP\nJan. 21, 1885\nDATE MRS OF Evelyn BIRTH (Month, Daugherty day, year) 359S. ackson St., Frankfort, Ind.\nsister\nSingle\nMarried\nSeparated\nWidowed\nDivorced\nWHAT LANGUAGES DO YOU SPEAK?\nEnglish\nYES\nNO\nHIGH SCHOOL GRADUATE\nNAME OF COLLEGE OR\nDEGREE OR\nUNIVERSITY ATTENDED\nLOCATION\nINCLUSIVE DATES\nDIPLOMA\nMAJOR\nTeachers College\nP.H.Organyphan\nColumbia University NewYork N.Y.\n(iffling 15 / points for\nARE YOU CURRENTLY\nYES\nNO\nREGISTERED IN (State)\nBS. Degree)\nARE YOU CURRENTLY A MEMBER OF THE AMERICAN\nYES\nNO\nREGISTERED?\nnewylosk\nNURSES' ASSOCIATION?\nx\nPRESENT EMPLOYMENT If not employed, check\nPOSITION TITLE (H.N., P.D. inst., staff nurse, etc.)\nSERVICE (Medicine, surgery, etc.)\nExecutive Secretary\nNAME OF HOSPITAL OR ORGANIZATION BY WHOM EMPLOYED\nCITY\nSTATE\nHEALTH American nurser Association\nnewyork,\nU.Y-\nIF OTHER THAN GOOD, SPECIFY NATURE AND ANTICIPATED DURATION OF DISABILITY\ngood 1\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\n1. Teach home\nYES\nNO\nAttend an instructors' training program, 11 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, if\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?\nIF UNABLE TO SERVE, GIVE MAJOR REASONS.\nYOUR DATE Janish VALUE AS A RED CROSS 20, NURSE 1945\nSIGNATURE the / Scort\nDEPENDS ON YOUR ABILITY AND WILLINGNESS TO SERVE AND YOUR FAITHPULNESS IN\nKEERING US INFORMED OF YOUR ADDRESS. PLEASE FILL IN THIS QUESTIONNAIRE AND RETURN IT PROMPTLY TO THE\nNurs ditment Committee\nCOMMITTEE NAMED BELOW.\nATTENTION\nNeesau County Chapter\nFill in committee name and address before sending questionnaire to nurse.\nSECRETARY\nAMERICAN RED CROSS\nNURSE RECRUITMENT\n264 Old Country Road\nCOMMITTEE\nMineola, N. I!\n78504M\nFORM 1045 Rev. July 1945"
}