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5 5 a for RED CROSS BADGE NUMBER AMERICAN RED CROSS 29668 NURSING SERVICES MILITARY SERIAL NUMBER ANNUAL QUESTIONNAIRE - 1945 CHECK IF YOUR LAST NAME HAS CHANGED I NAME (Last, first, middle) TELEPHONE NO. IF MARRIED, GIVE MAIDEN NAME Shuford - HUSBAND' S NAME mean Agnes wa-3-2797 5 & PERMANENT ADDRESS (Street, city, zone, county, state) PRESENT ADDRESS (Street, city, zone, county, state) 1372 Rivardida Dr. ny. 33.1n.4 NAME AND ADDRESS OF NEAREST RELATIVE OR FRIEND IN THE UNITED STATES 1372 Revinde W. n.4.33- TRELATIONSHIP n.ycu.ny min Camille Sheford (Samead.) Sister DATE OF BIRTH (Month, day, year) gamanin 21, 1886 Single Married Separated Widowed Divorced WHAT LANQUAGES DO YOU SPEAK? YES NO 1-AME OF COLLEGE OR English HIGH SCHOOL GRADUATE L DEGREE OR ATTENDED Hood College LOCATION Fredaich made LUSIVE DATES 1905-08 DIPLOMA Ba. MAJORE ARE YOU CURRENTLY YES NO REGISTERED IN (State) ARE YOU CURRENTLY A MEMBER OF THE AMERICAN YES NO REGISTERED? N.4 NURSES' ASSOCIATION? checkmark_ntt PRESENT EMPLOYMENT If not employed, check POSITION TITLE (H.N., P.D., inst., staff nurse, etc.) SERVICE (Medicine, surgery, etc.) Technica allain Clinic NAME OF HOSPITAL OR ORGANIZATION BY WHOM EMPLOYED CITY STATE Preplylinin Hospital n.4. n.4. HEALTH "Good IF OTHER THAN GOOD, SPECIFY NATURE AND ANTICIPATED DURATION OF DISABILITY 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, 1f offered. (Funds are available for YES NO nursing classes v training home nursing instructors. See local chapter.) 2 2. Serve in case YES NO only in home community Attend disaster institutes, if YES NO 03 of d!saster In other communities offered, in preparation for service e 3. Teach nurse's YES NO 4. Accept membership on chapter com- YES NO 5. Assist with other chapter YES NO L 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? 2 IF UNABLE TO SERVE, GIVE MAJOR REASONS. age. DATE SIGNATURE aug. 28. 1945 Caper m. Shuford. YOUR VALUE AS A RED CROSS NURSE DEPENDS ON YOUR ABILITY AND WILLINGNESS TO SERVE AND YOUR PAITHFOLNESS IN KEEPING US INFORMED OF YOUR ADDRESS. PLEASE FILL IN THIS QUESTIONWAIRE AND RETURN If PROMPTLY TO THE COMMITTES NAMED BELOW. ATTENTION Fill in committee name and address before sending questionnaire to nurse. NURSE RECRUITMENT CENTER SECRETARY 2 EAST 37TH STREET NURSE RECRUITMENT NEW YORK 16, N.Y. 09/20/45 COMMITTEE 78504M FORM 1045 Rev. July 1945

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