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THE AMERICAN RED CROSS
DEPARTMENT OF NURSING
Application for Enrollment
(To be filled out entirely in applicant's handwriting and each question answered fully.)
d/s
1. Name of applicant in full Theresa Jane Hinson
2. Address in full, Street 6802 Carrigic City Cleveland State Ohio
you
3. Date of birth aug. 21- 1884
Place of birth City View Ontario Canader
4.
Are you married, singlé or a widow ? single
Are you a citizen of the United States ? m
5. Have you any physical defects or tendency to constitutional or pulmonary trouble ? mi
Are you physically strong and healthy ? yes
S
6.
Name educational institutions attended before entering training school, stating number of years at each and
with private teacher egnal to one year high school.
from which you were graduated S.S. no.II nepean 10yrs. also two terms
7. What lánguages other than English do you speak none
8. Occupation before entering training school none
9. From what hospital training school did you receive your diploma ? H Clain Hospital
City and state eleveland Ohio Date of graduation november 3th 1908
10. Character of hospital: General ? yes
Special ?
Private ?
11. Did your training include obstetrics yes Care of men ? yes Children ? yes Contagious diseases ? m
12. Daily average number of patients in hospital during training GO
13. Name and address of superintendent of training school under whom received
Length of course 3yrs
miss Renter. (Min yuill at Womans you Hospital training mis my many Kearns
14. If your training as a nurse was received in more than one hospital, give name, location and time spent in each
Womans Hosp. New York City n.y. 6mo. Graduated nov. 4th 1914
15.
Of
Health nursing. Ohio sliate Distrittess
what nursing organizations are you a member ? The national Organization for Public
16. Which, if any, is affiliated with the American Nurses Association
17. name of of at least one
Give and address secretary of these organizations Anis AB. Stevens
18. Are you a registered nurse ? yes In what state ? Ohio Date of registration 1-11-16 Number 2894
Duvision of Health City Hall. Cleveland. O.
19. How and where employed since graduation:
Give dates with months:
Name and address of employers
night superviser
10-1-08-133-1-0-09
Stelain Hospital E4stt Helain
Private nursing
3-1-09-7-11
7-1-111-10-18
D.of H Cleveland Ohio
N
n
61
1-1910-4-11917
'
?
4
"
10
"
"
"
7-5-1918
,
"
"
et
"
(Specify for which of the following services you wish to be considered.)
20. War service, wherever needed yes
When available Oct 1st 1918
21. Instructor, Elementary Hygiene
Are you willing to take the oath of allegiance ? yes
23. Name and permanent address of nearest relative. Mrs. wm Stinson or for War Service yes
22. Public Health Nursing yes In Town and Country Nursing Service
Date 7-124-18
City View Ont. Canada
Signature of Nurse
To the Committee:
2
A.
This blank is to be sent to applicant with circular letter D. M. R. 7, together with Forms D. M. R. 2, 11, 29 and
after 11, should approval and endorsement by Local Committee, with credentials (Forms 3 and 4), together with Forms 10
R. C. 150. Application forms (except of a nurse desiring to enroll for the Town and Country Nursing Service)
American Red Cross, Washington, D. C.
be forwarded through the Director of the Bureau of Nursing in your Division to the Department of Nursing, and
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 Washing-
ton by the Local Committee, from whence credentials will be procured.
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"ocrText": "THE AMERICAN RED CROSS\nDEPARTMENT OF NURSING\nApplication for Enrollment\n(To be filled out entirely in applicant's handwriting and each question answered fully.)\nd/s\n1. Name of applicant in full Theresa Jane Hinson\n2. Address in full, Street 6802 Carrigic City Cleveland State Ohio\nyou\n3. Date of birth aug. 21- 1884\nPlace of birth City View Ontario Canader\n4.\nAre you married, singlé or a widow ? single\nAre you a citizen of the United States ? m\n5. Have you any physical defects or tendency to constitutional or pulmonary trouble ? mi\nAre you physically strong and healthy ? yes\nS\n6.\nName educational institutions attended before entering training school, stating number of years at each and\nwith private teacher egnal to one year high school.\nfrom which you were graduated S.S. no.II nepean 10yrs. also two terms\n7. What lánguages other than English do you speak none\n8. Occupation before entering training school none\n9. From what hospital training school did you receive your diploma ? H Clain Hospital\nCity and state eleveland Ohio Date of graduation november 3th 1908\n10. Character of hospital: General ? yes\nSpecial ?\nPrivate ?\n11. Did your training include obstetrics yes Care of men ? yes Children ? yes Contagious diseases ? m\n12. Daily average number of patients in hospital during training GO\n13. Name and address of superintendent of training school under whom received\nLength of course 3yrs\nmiss Renter. (Min yuill at Womans you Hospital training mis my many Kearns\n14. If your training as a nurse was received in more than one hospital, give name, location and time spent in each\nWomans Hosp. New York City n.y. 6mo. Graduated nov. 4th 1914\n15.\nOf\nHealth nursing. Ohio sliate Distrittess\nwhat nursing organizations are you a member ? The national Organization for Public\n16. Which, if any, is affiliated with the American Nurses Association\n17. name of of at least one\nGive and address secretary of these organizations Anis AB. Stevens\n18. Are you a registered nurse ? yes In what state ? Ohio Date of registration 1-11-16 Number 2894\nDuvision of Health City Hall. Cleveland. O.\n19. How and where employed since graduation:\nGive dates with months:\nName and address of employers\nnight superviser\n10-1-08-133-1-0-09\nStelain Hospital E4stt Helain\nPrivate nursing\n3-1-09-7-11\n7-1-111-10-18\nD.of H Cleveland Ohio\nN\nn\n61\n1-1910-4-11917\n'\n?\n4\n\"\n10\n\"\n\"\n\"\n7-5-1918\n,\n\"\n\"\net\n\"\n(Specify for which of the following services you wish to be considered.)\n20. War service, wherever needed yes\nWhen available Oct 1st 1918\n21. Instructor, Elementary Hygiene\nAre you willing to take the oath of allegiance ? yes\n23. Name and permanent address of nearest relative. Mrs. wm Stinson or for War Service yes\n22. Public Health Nursing yes In Town and Country Nursing Service\nDate 7-124-18\nCity View Ont. Canada\nSignature of Nurse\nTo the Committee:\n2\nA.\nThis blank is to be sent to applicant with circular letter D. M. R. 7, together with Forms D. M. R. 2, 11, 29 and\nafter 11, should approval and endorsement by Local Committee, with credentials (Forms 3 and 4), together with Forms 10\nR. C. 150. Application forms (except of a nurse desiring to enroll for the Town and Country Nursing Service)\nAmerican Red Cross, Washington, D. C.\nbe forwarded through the Director of the Bureau of Nursing in your Division to the Department of Nursing, and\nIn case the application forms of a nurse desiring to enroll for the Town and Country Nursing Service are sent\nto the Local Committee, instead of to Washington, as instructed, such forms should be forwarded at once to Washing-\nton by the Local Committee, from whence credentials will be procured."
}