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RED
AMERICAN RED CROSS
CROSS BADGE NUMBER 21654.
NURSING SERVICES
MILITARY SERIAL NUMBER
forgotton
ANNUAL QUESTIONNAIRE - 1945
CHECK IF YOUR LAST NAME HAS CHANGED
NAME (Last, first, middle)
TELEPHONE NO.
Wilem Harriet
519 Plyin
IF MARRIED, GIVE MAIDEN NAME
HUSBAND'S NAME
PERMANENT ADDRESS (Street, city, zone, county, state)
PRESENT ADDRESS (Street, city, zone, county, state
1320 n 10 H 16
Psymouth Wric
NAME Wildegard AND ADDRESS Wilson Plymouth His RELATIONSHIP Sinter
OF NEAREST RELATIVE OR FRIEND IN THE UNITED STATES
DATE while OF BIRTH Oree (Month, day, + year) 21/17
Single
Married
Separated
Widowed
Divorced
WHAT LANGUAGES DO YOU SPEAK?
YES
NO
suglish OF COLLEGE OR german
HIGH SCHOOL GRADUATE
NAME
DEGREE OR
UNIVERSITY ATTENDED
LOCATION
INCLUSIVE DATES
DIPLOMA
MAJOR
good Lake side Houst nnd out of existance - Mayo Horpl of
ARE Mo YOU R. CURRENTLY thorge YES of Seotia NO REGISTERED Happin IN (State) moor ARE YOU CURRENTLY for Cauada A MEMBER OF THE AMERICAN Woon young YES NO
Rochests mink Operating Ropu 6 ms this couyce interest.
REGISTERED?
yes
NURSES ASSOCIATION?
our seas - 6 wo PRESENT EMPLOYMENT 1
POSITION staff nurse,
Jonnate OF HOSPITAL TITLE (H.N., OR ORGANIZATION P.D., us inst. BY WHOM EMPLOYED Brood etc.) SERVICE (Medicine CITY surgery, etc.) STATE
NAME
for your -
4
itc.-
HEALTH
OTHER THAN GOOD, SPECIFY NATURE AND ANTICIPATED DURATION OF DISABILITY
good
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
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.
DATE
SIGNATURE
YOUR VALUE AS A RED CROSS NURSE DEPENDS ON YOUR ABILITY AND WILLINGNESS TO SERVE AND YOUR FAITHFULNESS IN
KEEPING US INFORMED OF YOUR ADDRESS. PLEASE FILL IN THIS QUESTIONNAIRE AND RETURN IT PROMPTLY TO THE
COMMITTEE NAMED BELOW.
ATTENTION
Fill in committee name and address before sending questionnaire to nurse.
SECRETARY
Mrs. OHo
NURSE RECRUITMENT
chairwan
E 1/21
COMMITTEE
78504M
413 So. 14 ST. Shebay gan Win.
FORM 1045 Rev. July 1945
Page data
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Document data
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- Core
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DTO data
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Context sent to Scholar
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"ocrText": "RED\nAMERICAN RED CROSS\nCROSS BADGE NUMBER 21654.\nNURSING SERVICES\nMILITARY SERIAL NUMBER\nforgotton\nANNUAL QUESTIONNAIRE - 1945\nCHECK IF YOUR LAST NAME HAS CHANGED\nNAME (Last, first, middle)\nTELEPHONE NO.\nWilem Harriet\n519 Plyin\nIF MARRIED, GIVE MAIDEN NAME\nHUSBAND'S NAME\nPERMANENT ADDRESS (Street, city, zone, county, state)\nPRESENT ADDRESS (Street, city, zone, county, state\n1320 n 10 H 16\nPsymouth Wric\nNAME Wildegard AND ADDRESS Wilson Plymouth His RELATIONSHIP Sinter\nOF NEAREST RELATIVE OR FRIEND IN THE UNITED STATES\nDATE while OF BIRTH Oree (Month, day, + year) 21/17\nSingle\nMarried\nSeparated\nWidowed\nDivorced\nWHAT LANGUAGES DO YOU SPEAK?\nYES\nNO\nsuglish OF COLLEGE OR german\nHIGH SCHOOL GRADUATE\nNAME\nDEGREE OR\nUNIVERSITY ATTENDED\nLOCATION\nINCLUSIVE DATES\nDIPLOMA\nMAJOR\ngood Lake side Houst nnd out of existance - Mayo Horpl of\nARE Mo YOU R. CURRENTLY thorge YES of Seotia NO REGISTERED Happin IN (State) moor ARE YOU CURRENTLY for Cauada A MEMBER OF THE AMERICAN Woon young YES NO\nRochests mink Operating Ropu 6 ms this couyce interest.\nREGISTERED?\nyes\nNURSES ASSOCIATION?\nour seas - 6 wo PRESENT EMPLOYMENT 1\nPOSITION staff nurse,\nJonnate OF HOSPITAL TITLE (H.N., OR ORGANIZATION P.D., us inst. BY WHOM EMPLOYED Brood etc.) SERVICE (Medicine CITY surgery, etc.) STATE\nNAME\nfor your -\n4\nitc.-\nHEALTH\nOTHER THAN GOOD, SPECIFY NATURE AND ANTICIPATED DURATION OF DISABILITY\ngood\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, 1f 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.\nDATE\nSIGNATURE\nYOUR VALUE AS A RED CROSS NURSE DEPENDS ON YOUR ABILITY AND WILLINGNESS TO SERVE AND YOUR FAITHFULNESS IN\nKEEPING US INFORMED OF YOUR ADDRESS. PLEASE FILL IN THIS QUESTIONNAIRE AND RETURN IT PROMPTLY TO THE\nCOMMITTEE NAMED BELOW.\nATTENTION\nFill in committee name and address before sending questionnaire to nurse.\nSECRETARY\nMrs. OHo\nNURSE RECRUITMENT\nchairwan\nE 1/21\nCOMMITTEE\n78504M\n413 So. 14 ST. Shebay gan Win.\nFORM 1045 Rev. July 1945"
}