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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"
}