Parachuting Center adult registration forms (photocopied set)
Title revised to match the document’s own text.
Original title: Elsinore Parachuting Center adult registration forms (photocopied set)
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Id: Cooper-Part-17:289-296
Subject: Cooper Files: Cooper-Part-17:289-296 Document: Parachuting Center adult registration forms (photocopied set) Id: Cooper-Part-17:289-296 Page: https://cooper.theunsolved.net/documents/Cooper-Part-17%3A289-296 What is wrong (title, date, type, which pages belong together, copies)? What does the scan show?
A person reads every report. Corrections are made by hand, to the data — titles, dates, names, which pages belong together — never to the scans, and they can take a while to appear.
FBI 164-81, Vault Part 17 pp. 289–296 (DB Cooper-5119–5126), Form — cooper.theunsolved.net/documents/Cooper-Part-17%3A289-296
PARACHUTING CENTER ADULT REGISTRATION FORM (Check Only One Please)
City: [illegible] CALIF Zip Code: [illegible] Name: [redacted b6/b7C] High School: Phone: [redacted b6/b7C] Weight: [illegible] Height: [illegible] ☐ Attending ☐ Did Not Complete Occupation: [illegible] ☐ Graduated Date of Birth: [redacted b6/b7C] College; Please give name of: Present Address: [redacted b6/b7C] ☐ Attending City: [illegible] Zip Code: [illegible] ☐ Attended Phone: [redacted b6/b7C] ☐ Graduated Other: ___
How did you learn of the center? (Check Only One Please) ☐ "A Sport Is Born" Movie ☐ Magazine Article ☐ Sports Show (Which) ___ ☐ Yellow Pages Ad ☐ World Championship 1962 ☐ Friend (Name) ___ ☐ Word of Mouth ☐ Lecture Other ___
HOW DID YOU TRAVEL TO CENTER? ☐ Plane ☐ Car ☐ Bus ☐ Other ___
MEDICAL STATEMENT FOR UNDERGOING PARACHUTE TRAINING AND JUMPING
I hereby certify that I am not aware of and am not under treatment for any physical infirmity or chronic ail- ment, or injury of any nature, and that I have normal vision or have corrective lenses, and that I have never been treated for any of the following:
1.) Cardiac or pulmonary condition or disease 5.) Nervous disorder 2.) High or low blood pressure 6.) Diabetes 3.) Fainting spells, or convulsions 7.) Kidney or related diseases 4.) Hard of hearing
Signature: [illegible handwritten signature]
INFORMATION — AFTER READING, SIGNING AND DATING BOTH SIDES — TURN FORM OVER — READ AND COMPLETE OTHER SIDE
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PARACHUTING CENTER ADULT REGISTRATION FORM (Check Only One Please)
Permanent Address: [redacted b6/b7C] City: [redacted b6/b7C] Zip Code: [redacted b6/b7C] Name: Joel [guess: Anoclet] [redacted b6/b7C] Phone: [redacted b6/b7C] High School: Age: [illegible] Sex: [illegible] ☐ Attending Occupation: [illegible] ☐ Did Not Complete Date of Birth: [redacted b6/b7C] ☐ Graduated
Present Address: [redacted b6/b7C] City: [illegible] Zip Code: [illegible] Phone: [redacted b6/b7C]
College; Please give name of: ☐ Attending ☐ Attended ☐ Graduated Other: ___
How did you learn of the center? (Check Only One Please) ☐ "A Sport Is Born" Movie ☐ Magazine Article ☐ Sports Show (Which) ___ ☐ Yellow Pages Ad ☐ World Championship 1962 ☐ Friend (Name) ___ ☐ Word of Mouth ☐ Lecture Other ___
HOW DID YOU TRAVEL TO CENTER? ☐ Plane ☐ Car ☐ Bus ☐ Other ___
MEDICAL STATEMENT FOR UNDERGOING PARACHUTE TRAINING AND JUMPING
I hereby certify that I am not aware of and am not under treatment for any physical infirmity or chronic ail- ment, or injury of any nature, and that I have normal vision or have corrective lenses, and that I have never been treated for any of the following:
1.) Cardiac or pulmonary condition or disease 5.) Nervous disorder 2.) High or low blood pressure 6.) Diabetes 3.) Fainting spells or convulsions 7.) Kidney or related diseases 4.) Hard of hearing
Signature: [illegible handwritten signature] Date: [illegible]
INFORMATION — AFTER READING, SIGNING AND DATING THIS SIDE — TURN FORM OVER — READ AND COMPLETE OTHER SIDE
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DB Cooper-5119
ADULT R[redacted]STRATION FORM
[redacted] A. [redacted] Name: [redacted] CITY: [guess: CALI]F. [redacted] Age: [redacted] Weight/[redacted] Height/[redacted] Address: [redacted] St./State: [redacted] of Lists: [redacted] Address: [redacted] State: [redacted] Z.ip Code: [redacted]
(Check Only One Please) High School: Attending Did Not Complete Graduated
College: Please give name of: Attending Attended Graduated
Other: ......
How did you learn of the center? (Check Only One Please) "A Sport is Born" Movie Magazine Article Sports Show (Which) Yellow Pages Ad World Championship 1962 Friend (Name): [redacted] Word of Mouth Lecture Other: ......
HOW DID YOU TRAVEL TO CENTER? Plane Bus Other Car [checked]
MEDICAL STATEMENT FOR UNDERGOING PARACHUTE TRAINING AND JUMPING
I hereby certify that I am not aware of and am not under treatment for any physical infirmity or chronic ail- ment, or injury of any nature, and that I have normal vision or have corrective lenses, and that I have [redacted] never been treated for any of the following:
1.) Cardiac or pulmonary condition or disease 5.) Nervous disorder 2.) Major or low blood pressure 6.) Diabetes 3.) Fainting spells or convulsions 7.) Kidney or related diseases 4.) Hard of hearing
[signature line redacted]
AFTER READING, SIGNING AND PLACING THIS SIDE -- TURN FORM OVER -- READ AND COMPLETE OTHER SIDE
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PARACHUTING CENTER ADULT REGISTRATION FORM
Permission: [redacted] C[redacted] Name: [redacted] CAIT[redacted] [redacted] Phone: [redacted] Weight/[redacted] Height/[redacted] Occupation: [redacted] Date of Birth: [redacted] Present Address: [redacted] City: [redacted] State/[redacted] Zip Code: [redacted] Phone: [redacted] U.S.P.A.
(Check Only One Please) High School: Attending Did Not Complete Graduated
College: Please give name of: Attending Attended Graduated
Other: ......
How did you learn of the center? (Check Only One Please) "A Sport is Born" Movie Magazine Article Sports Show (Which) Yellow Pages Ad World Championship 1962 X Friend (Name): [redacted] Word of Mouth Lecture Other: ......
HOW DID YOU TRAVEL TO CENTER? Plane X Car Bus Other ______
MEDICAL STATEMENT FOR UNDERGOING PARACHUTE TRAINING AND JUMPING
I hereby certify that I am not aware of and am not under treatment for any physical infirmity or chronic ail- ment, or injury of any nature, and that I have normal vision or have corrective lenses, and that I have [redacted] never been treated for any of the following:
1.) Cardiac or pulmonary condition or disease 5.) Nervous disorder 2.) Major or low blood pressure 6.) Diabetes 3.) Fainting spells or convulsions 7.) Kidney or related diseases 4.) Hard of hearing
[signature redacted]
Date 8 / 16 / 71
AFTER READING, SIGNING AND PLACING THIS SIDE -- TURN FORM OVER -- READ AND COMPLETE OTHER SIDE
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b6 b7C
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-16-
DB Cooper-5120
[REDACTED] [illegible] ADULT CLUB/CENTER [illegible] PROFIT / [illegible]
Circle Only One Please
How did you learn to [illegible] (Check Only One [illegible]) [illegible] "A Spot in Born" [illegible] [ ] Magazine Article [ ] Sports Show (Which) [illegible] [ ] Yellow Pages Ad [ ] World Championship [illegible] [ ] Friend (name) [illegible] [ ] Word of Mouth [ ] Other
[REDACTED - multiple lines]
[illegible] ...confidentiality of [illegible] for [illegible] ...if you wish to be a [illegible] I know[s]
[REDACTED BLOCK]
café [illegible]
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PARACHUTING CLUB/CENTER
ADULT REGISTRATION FORM
Circle Only One Please How did you learn about us (Check Only One [illegible]) Age [illegible] [ ] "A Spot in Born" [illegible] [illegible] at Company [ ] Magazine Article [illegible] Employed [ ] Sports Show (Which) [ ] Yellow Pages Ad Circle Please give name of: [ ] World Championship [guess: Prize] [ ] [illegible] [ ] Friend (name) [illegible] [illegible] [ ] Word of Mouth [ ] [illegible] [ ] Other [REDACTED]
Other [illegible] HOW DID YOU TRAVEL TO CENTER? [illegible] ...do [illegible] [ ] Plane M Car [ ] Bus [ ] Other [illegible]
[illegible] UNRESOLVED PHYSICAL TRAINING AND JUMPING
[illegible] ...and [illegible] under the terms, if for any physical infirmity or chronic ail- ments or if [illegible] normal vision or have corrective lenses, and that I have
[illegible] (a) Nervous disorder [illegible] (b) Diabetes [illegible] (7.) Kidney or related diseases
[REDACTED BLOCK] Date 2-1-7[illegible]
[illegible] DO NOT SIGN THIS [illegible] -- TURN FORM OVER -- READ AND COMPLETE OTHER SIDE
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DB Cooper-5121
PARACHUTING CENTER ADULT REGISTRATION FORM
Person [redacted] Cal [redacted] C. [redacted] Phone [redacted] Occupation [redacted] Date of birth [redacted] City [redacted] State [redacted] Zip [redacted] Present Address [redacted] City [redacted] Phone [redacted] Zip Code [redacted]
How did you learn of the center? __ Daily or Own Pleasure/Movie __ Magazine Article __ Sports Show (Where) __ Yellow Pages Ad __ World Championship 1962 __ Friend/Neighbor __ Word of Mouth __ Lecture __ Other
b6 b7C
HOW DID YOU TRAVEL TO CENTER? __ Phone __ Car __ Bus __ Other
MEDICAL STATEMENT FOR UNDERGOING PARACHUTE TRAINING AND JUMPING
I hereby certify that I am not aware of and am not under treatment for any physical infirmity or chronic ail- ment, or injury of any nature, and that I have normal vision or have corrective lenses, and that I have never been treated for any of the following:
1. Cardiac or pulmonary condition or disease 5. Nervous disorder 2. High or low blood pressure 6. Diabetes 3. Fainting spells or convulsions 7. Kidney or related diseases 4. Hard of hearing
Date: [illegible] [signature area illegible]
-- TURN FORM OVER -- READ AND COMPLETE OTHER SIDE --
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PARACHUTING CENTER ADULT REGISTRATION FORM
[redacted personal information fields]
Cal [redacted]
Date of birth [redacted]
How did you learn of the center? __ Daily or Own Pleasure/Movie __ Magazine Article __ Sports Show (Where) __ Yellow Pages Ad __ World Championship 1962 __ Friend/Neighbor __ Word of Mouth __ Lecture __ Other
b6 b7C
College, [illegible] or major [illegible] American [illegible] Amount Paid [redacted] Charge Additional [illegible]
HOW DID YOU TRAVEL TO CENTER? __ Phone __ Car __ Bus __ Other
MEDICAL STATEMENT FOR UNDERGOING PARACHUTE TRAINING AND JUMPING
I hereby certify that I am not aware of and am not under treatment for any physical infirmity or chronic ail- ment, or injury of any nature, and that I have normal vision or have corrective lenses, and that I have never been treated for any of the following:
1. Cardiac or pulmonary condition or disease 5. Nervous disorder 2. High or low blood pressure 6. Diabetes 3. Fainting spells or convulsions 7. Kidney or related diseases 4. Hard of hearing
Date: [illegible] [signature area illegible]
-- TURN FORM OVER -- READ AND COMPLETE OTHER SIDE --
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DB Cooper-5122
PARACHUTING CENTER ADULT REGISTRATION FORM
Personal Address City _________ State _________ Zip Code _________ Age _________ Weight _________ Height _________ Occupation _________ Date of Birth Day _________ Month _________ Year _________ Present Address _________ City _________ State _________ Zip Code _________ Phone _________
(Check Only One Please) High School Attending Did Not Complete Graduated
College, Please give name of: Attending Attended Graduated Other _________
HOW DID YOU TRAVEL TO CENTER? Plane By-Car Bus Other
How did you learn (Check Only One) "A Sport Is Born" (?) Magazine Article Sports Show /What Yellow Pages Ad World Champion Friend (Name) _ Word of Mouth Lecture Other _________
b6 b7C
MEDICAL STATEMENT FOR UNDERGOING PARACHUTE TRAINING AND JUMPING
I hereby certify that I am not under treatment for any physical infirmity or chronic ail- ment, or [illegible] and am not under [illegible] or have normal vision or have corrective lenses, and that I have never [illegible] a [illegible] of the following conditions:
1. Chronic or pulmonary condition, or similar disease 2. Bone or joint problems 3. Fainting spells or unconsciousness 4. [illegible] of heart [illegible] 5. Nervous disorder 6. Diabetes 7. Kidney or related diseases
PLEASE TURN OVER - READ AND COMPLETE
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PARACHUTING CENTER ADULT REGISTRATION FORM
Personal Address City _________ State _________ Zip Code _________ Age _________ Weight _________ Height _________ Occupation _________ Date of Birth Day _________ Month _________ Year _________ Present Address _________ City _________ State _________ Zip Code _________ Phone _________
(Check Only One Please) High School Attending Did Not Complete Graduated
College, Please give name of: Attending Attended Graduated Other _________
HOW DID YOU TRAVEL TO CENTER? Plane [illegible] Car Other
How did you learn (Check Only One) "A Sport Is Born" (?) Magazine Article Sports Show /What Yellow Pages Ad World Champions Friend (Name) _ Word of Mouth Lecture Other _________
b6 b7C
MEDICAL STATEMENT FOR UNDERGOING PARACHUTE TRAINING AND JUMPING
I hereby certify that I am not under treatment for any physical infirmity or chronic ail- [illegible] or have normal vision or have corrective lenses, and that I have [illegible]
1. Chronic or pulmonary condition, or similar disease 2. Bone or joint problems 3. Fainting spells or unconsciousness 4. [illegible] of [illegible]
PLEASE TURN OVER
IMPORTANT - AFTER READING, SIGNING AND DATING THIS SIDE TURN FORM OVER READ AND COMPLETE
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DB Cooper-5123
ADULT REGISTRATION FORM (Check Only One Please)
Permanent Address: [redacted] Store (CAUF) Zip Code [illegible] Weight [illegible] height [illegible]
High School: ( ) Attending ( ) Did Not Complete ( ) Graduated
College: (Please give name of) ( ) Attending ( ) Attended [illegible] ( ) Graduated
Occupation: [illegible] Date of birth: [redacted] DAY MONTH YEAR Present Address: [redacted] City [illegible] State [illegible] Zip Code Phone [illegible]
How did you learn of the center? (Check Only One Please) ( ) "A Sport Is Born" Movie ( ) Magazine Article ( ) Sports Show (Which) ( ) Yellow Pages Ad ( ) World Championship 1962 ( ) Friend (Name) ( ) Word of Mouth ( ) Lecture Other [blank]
HOW DID YOU TRAVEL TO CENTER? ( ) Train ( ) Car ( ) Bus ( ) Other
MEDICAL STATEMENT FOR UNDERGOING PARACHUTE TRAINING AND JUMPING
I hereby certify that I am not aware of any condition or [guess: under] treatment for any physical infirmity or chronic ail- ment, of injury to any [guess: bone], and that I have normal vision and normal [guess: reflexes], and that I have never been [guess: rejected] for any of the following:
1. Cardiac or pulmonary condition or disease 5. [guess: Nervous] disorder 2. High or low blood pressure 6. [guess: Fainting] 3. [guess: Fainting] or loss of [guess: consciousness] 7. [guess: Kidney] or related diseases 4. [guess: Hernia] of rupture
IMPORTANT -- AFTER READING, SIGNING AND DATING THIS SIDE TURN FORM OVER -- READ AND COMPLETE OTHER SIDE
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PARACHUTING CENTER ADULT REGISTRATION FORM (Check Only One Please)
[Form is a duplicate of section 1 with same fields]
Permanent Address: [redacted] Store [illegible] Zip Code Weight [illegible] height [illegible]
High School: ( ) Attending ( ) Did Not Complete ( ) Graduated
College: (Please give name of) ( ) Attending ( ) Attended [illegible] ( ) Graduated
Occupation: [illegible] Date of birth: [redacted] Present Address: [redacted] City [illegible] State [illegible] Zip Code Phone [illegible] U.S.P.A.
How did you learn of this center? (Check Only One Please) ( ) "A Sport Is Born" Movie ( ) Magazine Article ( ) Sports Show (Which) ( ) Yellow Pages Ad ( ) World Championship 1962 ( ) Friend (Name) ( ) Word of Mouth ( ) Lecture Other [blank]
HOW DID YOU TRAVEL TO CENTER? ( ) [guess: Plane] ( ) Car ( ) Bus ( ) Other
MEDICAL STATEMENT FOR UNDERGOING PARACHUTE TRAINING AND JUMPING
[Same medical statement text as section 1]
1. Cardiac or pulmonary condition or disease 5. Nervous disorder 2. High or low blood pressure 6. [guess: Fainting] 3. [guess: Forming] [guess: spell] or [illegible] 7. Kidney or related diseases 4. Hernia of [guess: hearing]
Date [illegible]
IMPORTANT -- AFTER READING, SIGNING AND DATING THIS SIDE TURN FORM OVER -- READ AND COMPLETE OTHER SIDE
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DB Cooper-5124
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-14-
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b6 b7C
ADULT REGISTRATION FORM
[Personal information fields - mostly blank] C___ | NY | __ High School: Pr_v_s | __ | __ | __ ___ "A Sport is Born" Movie Occupation: Magazine Article Date of Birth | DAY | MONTH | YEAR | / Sports Show (Which) Present Address Yellow Pages Ad City | State | Zip Code World Championship 19__ Phone __ Friend (Name) __ ___ Word of Mouth Lecture Other
Check Only One Please: How did you learn of the center? (Check Only One Please)
College, Please give name of: Attending Attended Graduated
Other
HOW DID YOU TRAVEL TO CENTER? __ [Train] __ Car __ Bus __ Other
MEDICAL STATEMENT FOR UNDERGOING PARACHUTE TRAINING AND JUMPING
I hereby certify that I am not under [guess: care] and not under treatment for any physical infirmity or chronic ail- ment, or infir[m]y of any nature, and that I have normal vision or have corrective lenses, and that I have never been treated for any of the following:
1.) Coronary or pulmonary condition or disease 5.) Nervous disorder 2.) High or low blood pressure 6.) Diabetes 3.) 7.) Kidney or related diseases 4.)
Signature | Date __ / __ / __
IMPORTANT -- AFTER READING, SIGNING AND DATING THIS SIDE -- TURN FORM OVER -- READ AND COMPLETE OTHER SIDE
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PARACHUTING CENTER ADULT REGISTRATION FORM
Per________ C___ | NY | __ | Zip Code Name | Age | We__nt__ | He_ght Occupation
Date of Birth | DAY | MONTH | YEAR Present Address City ______ | State | Zip Code
Phone __ __ __ /__ __ ___
Check Only One Please: How did you learn of the center? (Check Only One Please) High School: "A Sport is Born" Movie Attending Magazine Article Did Not Complete Sports Show (Which) Credentialed Yellow Pages Ad World Championship 1962 College, Please give name of: Friend (Name) Attending Word of Mouth Attended Lecture Graduated Other
Other
HOW DID YOU TRAVEL TO CENTER? __ Car __ Bus __ Other
MEDICAL STATEMENT FOR UNDERGOING PARACHUTE TRAINING AND JUMPING
I hereby certify that I am not under [guess: care] and not under treatment for any physical infirmity or chronic ail- ment, or infir[m]y of any nature, and that I have normal vision or have corrective lenses, and that I have never been treated for any of the following:
1. Coronary or pulmonary condition or disease 5. Nervous disorder 2. High or low blood pressure 6. [guess: Diabetes] 3. Forming spells or convulsions 7. Kidney or related diseases 4. None of above
Signature | Date __ / __ / __
IMPORTANT -- AFTER READING, SIGNING AND DATING THIS SIDE -- TURN FORM OVER -- READ AND COMPLETE OTHER SIDE
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-15-
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DB Cooper-5125
ADULT REGISTRATION FORM
Permanent Address: [redacted] State: [redacted] Zip Code: [blank] Phone: [blank] Age: [blank] Weight: 150 Height: 5' 7" Occupation: [blank] Date of Birth: [blank] DAY [blank] MONTH [blank] YEAR Sex: M Present Address: [guess: Burns Ave] [guess: 46904] City: [blank] State: [blank] Zip Code: [blank] Phone: [blank] S P A: [blank]
(Check Only One Please) High School: [ ] Attending [ ] Did Not Complete [ ] Graduated
College, Please give name of: [ ] Attending [ ] Attended [ ] Graduated Other: [blank]
How did you learn of this center? (Check Only One Please) [ ] "A Sport is Born" Movie [ ] Magazine Article [ ] Sports Show (Which) [ ] Yellow Pages Ad [ ] World Championship [guess: 1974] [X] Friend (Name) [redacted] [ ] Word of Mouth [ ] Lecture [ ] Other
HOW DID YOU TRAVEL TO CENTER? [ ] Phone [X] Car [ ] Bus [ ] Other
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MEDICAL STATEMENT FOR UNDERGOING PARACHUTE TRAINING AND JUMPING
I hereby certify that I am not aware of and am not under treatment for any physical infirmity or chronic ailment, or injury of any nature, and that I have abnormal vision or have corrective lenses, and that I have never been treated for any of the following:
1. Cardiac or pulmonary condition or disease 5. Nervous disorder 2. High or low blood pressure 6. Diabetes 3. Fainting spells or convulsions 7. Kidney or related diseases 4. Disorders of hearing
Signature: [redacted] Date: 1/24/71
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IMPORTANT -- AFTER READING, SIGNING AND DATING THIS SIDE TURN FORM OVER -- READ AND COMPLETE OTHER SIDE [illegible fine print line below]
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-76- DB Cooper-5126
Serials: 5120