Part 11
19. Is she subject to any functional disturbance?
I have on the day of 191 seen and examined and hereby certify that she is apparently in good health, that she is not labouring under any deformity, and is, in my opinion, both physically and mentally competent to undertake duty in a Military Hospital, and is [*]A. Fit for General Service.
B. Fit for Home Service only.
C. Unfit.
_Date (Signed) Address_
[Footnote *: Kindly delete categories which do not apply.]
Reference No.: J.W. 19c.
JOINT WOMEN'S V.A.D. DEPARTMENT.
Territorial Forces a.s.sociation. British Red Cross Society. Order of St.
John of Jerusalem.
DEVONSHIRE HOUSE, PICCADILLY, LONDON. W1.
QUALIFICATIONS of Members of Women's Voluntary Aid Detachments for Nursing Service or General Service.
1. (a) Name in full (_Mrs. or Miss_).
(b) If Married state Maiden Name.
2. Permanent Postal Address.
Present Postal Address.
3. Telephone No.
4. Telegraphic Address.
5. Detachment County and No.
B.R.C.S.
St. John Brigade.
St. John a.s.sociation.
6. Name and Address of Commandant of Detachment.
7. Rank in Detachment.
8. Time of Service in Detachment.
9. Age and Date of Birth.
10. Place and Country of Birth.
11. Nationality at Birth.
12. Present Nationality.
13. Height.
14. Weight.
15. Where Educated.
16. At what age did you leave school?
17. Whether Single, Married, or Widow.
18. If not Single, state Nationality of Husband.
19. Name and Address of Next-of-Kin or Nearest Relation residing in the British Isles.
20. Father's Nationality at Birth.
21. Mother's Nationality at Birth.
22. Father's Profession.
23. Religion.
24. (a) If you volunteer for nursing duties state what experience you have had in wards.
(b) Name and address of hospital.
(c) Date.
25. Certificates held.
26. (a) Nursing. (f) Motor Driver.
(b) Kitchen. (g) Laboratory Attendant.
(c) Clerical. (h) X-Ray Attendant.
(d) Storekeeping. (i) House Work.
(e) Dispenser. (j) Pantry Work.
27. State what experience and qualifications you have had for Categories in No. 26.
