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Form 1037
Rev. 3-1-26
THE AMERICAN NATIONAL RED CROSS NURSING SERVICE
Application for Enrollment
(To be filled out entirely in applicant's handwriting and each question answered fully.)
1. Name of applicant in full R.N.
2. Address in full Director Hened center TRad curs work
Box 314 - Tuekagee Institute, ala
3. Date of birth 3/3/1894 Race paper Place of birth Caulpeptor, Va
Birthplace of father bame Mother same Citizenship of father lenver
4. Are you married, single or a widow? m Are you a citizen of the United States? yes
5. How many years have you attended grammar school? 7 High school? 4 Normal school?
4
Private,
school? s College? 1 1/2 if tutored privately, name subjects covered and length of time
Physiology
6. 2 yrs mental Hygiene 2 yrs sociolog ejps.
That languages other than English do you speak?
(Underline those which you speak fluently.)
7. Occupation before entering training school
none
8.
From what hospital training school did you receive your diploma? Richard Hustual
Give City name and State at time Reduced, of graduation Date of graduation april 20', 1915
19
9. Character of hospital: General? yes Special?
Private? yes
10. Did your training include obstetrics yes Care of men? ge Children? yes Contagious diseases? 3 yes
11. Daily average number of patients in Hospital during training 80 Length of course yrs
12. Name and address of superinténdent of nurses under whom you received training
mis maggie L. Wellans R.N. state Gelyum Petersbury, va (hurse)
superving
13. If your training as a nurse was received in more than one hospital, give name, location and time spent in each
strent my time City Herpital Mediumed Hospital 11/2 years each
14. Of what nursing organizations are you a member? n.o.p.H.H.
Mb. of my pin 1313.
15.
Which, if any, if affiliated with the American Nurses' Association? n.o. P. H. n.
16. Give name and address of secretary of at least one of these organizations the General Director
of hopH.n is secretary
17. Are you a registered nurse? yesin what State? varalar Date of registration Va no 185 Number no 1258
3/11/18 cell 11/15/27
18. Type of work and length of .service since graduation:
Health Superviour, Rural scheme Heureco country Ruhunds 12 3 yrs.
" Deceton, colered Insurance companic Richurd, va
Teacher Home nursery classes ammthing Hephseleme Richeeral,
Home service tHeath Center Worker Red even chapter of
Jurkagee restitute all
Director (Present position) Health centr work tHeme sericce workenfRE) purkagee suct,
19. Will you be willing to accept active service if the United States becomes involved in war?
20. (a) If interested in accepting service within the near future, indicate choice: R. C. P. H. Nursing Instructor,
ye
Home Hygiene and Care of Sick, Army, Navy, U. S. Public Health Service, U. S. Veterans Bureau.
(b) Date upon which you will be available R.C. P. H. nursery Instructor
21. Are you willing to take the oath of allegiance?
1410 Tugg st, auguster Ga
relative (give relationship) sister) mis Susie Singlation
yes
22. Name and permanent address of near
Date
12/ 1/4/21 Signature of nurse P.H.
NOTE. Nurses who have had training or experience in Public Health Nursing will, in addition to the above, fill
out questions 23 and 24 on reverse side of this blank.
To The Local Committee:
This blank is to be sent to applicant with circular letter Form 1199, together with Forms 2, 1193 and A. R. C.
703. Application forms after approval and endorsement by Local Committee, with Forms 1244, 1189, and 1193
should be forwarded to National Headquarters or to the proper Branch Office.
(OVER)
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"ocrText": "Form 1037\nRev. 3-1-26\nTHE AMERICAN NATIONAL RED CROSS NURSING SERVICE\nApplication for Enrollment\n(To be filled out entirely in applicant's handwriting and each question answered fully.)\n1. Name of applicant in full R.N.\n2. Address in full Director Hened center TRad curs work\nBox 314 - Tuekagee Institute, ala\n3. Date of birth 3/3/1894 Race paper Place of birth Caulpeptor, Va\nBirthplace of father bame Mother same Citizenship of father lenver\n4. Are you married, single or a widow? m Are you a citizen of the United States? yes\n5. How many years have you attended grammar school? 7 High school? 4 Normal school?\n4\nPrivate,\nschool? s College? 1 1/2 if tutored privately, name subjects covered and length of time\nPhysiology\n6. 2 yrs mental Hygiene 2 yrs sociolog ejps.\nThat languages other than English do you speak?\n(Underline those which you speak fluently.)\n7. Occupation before entering training school\nnone\n8.\nFrom what hospital training school did you receive your diploma? Richard Hustual\nGive City name and State at time Reduced, of graduation Date of graduation april 20', 1915\n19\n9. Character of hospital: General? yes Special?\nPrivate? yes\n10. Did your training include obstetrics yes Care of men? ge Children? yes Contagious diseases? 3 yes\n11. Daily average number of patients in Hospital during training 80 Length of course yrs\n12. Name and address of superinténdent of nurses under whom you received training\nmis maggie L. Wellans R.N. state Gelyum Petersbury, va (hurse)\nsuperving\n13. If your training as a nurse was received in more than one hospital, give name, location and time spent in each\nstrent my time City Herpital Mediumed Hospital 11/2 years each\n14. Of what nursing organizations are you a member? n.o.p.H.H.\nMb. of my pin 1313.\n15.\nWhich, if any, if affiliated with the American Nurses' Association? n.o. P. H. n.\n16. Give name and address of secretary of at least one of these organizations the General Director\nof hopH.n is secretary\n17. Are you a registered nurse? yesin what State? varalar Date of registration Va no 185 Number no 1258\n3/11/18 cell 11/15/27\n18. Type of work and length of .service since graduation:\nHealth Superviour, Rural scheme Heureco country Ruhunds 12 3 yrs.\n\" Deceton, colered Insurance companic Richurd, va\nTeacher Home nursery classes ammthing Hephseleme Richeeral,\nHome service tHeath Center Worker Red even chapter of\nJurkagee restitute all\nDirector (Present position) Health centr work tHeme sericce workenfRE) purkagee suct,\n19. Will you be willing to accept active service if the United States becomes involved in war?\n20. (a) If interested in accepting service within the near future, indicate choice: R. C. P. H. Nursing Instructor,\nye\nHome Hygiene and Care of Sick, Army, Navy, U. S. Public Health Service, U. S. Veterans Bureau.\n(b) Date upon which you will be available R.C. P. H. nursery Instructor\n21. Are you willing to take the oath of allegiance?\n1410 Tugg st, auguster Ga\nrelative (give relationship) sister) mis Susie Singlation\nyes\n22. Name and permanent address of near\nDate\n12/ 1/4/21 Signature of nurse P.H.\nNOTE. Nurses who have had training or experience in Public Health Nursing will, in addition to the above, fill\nout questions 23 and 24 on reverse side of this blank.\nTo The Local Committee:\nThis blank is to be sent to applicant with circular letter Form 1199, together with Forms 2, 1193 and A. R. C.\n703. Application forms after approval and endorsement by Local Committee, with Forms 1244, 1189, and 1193\nshould be forwarded to National Headquarters or to the proper Branch Office.\n(OVER)"
}