Adult registration forms and medical statements for parachute training and jumping
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Original title: Photocopied Elsinore Parachuting Center adult registration forms and medical statements
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Id: Cooper-Part-55:103-110
Subject: Cooper Files: Cooper-Part-55:103-110 Document: Adult registration forms and medical statements for parachute training and jumping Id: Cooper-Part-55:103-110 Page: https://cooper.theunsolved.net/documents/Cooper-Part-55%3A103-110 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 55 pp. 103–110 (DB Cooper-23246–23253), Form — cooper.theunsolved.net/documents/Cooper-Part-55%3A103-110
ADULT REGISTRATION FORM (Check Only One Please) High School [illegible] 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) ____ □ Word of Mouth □ Lecture Other ____
HOW DID YOU TRAVEL TO CENTER? □ Plane □ Car □ Bus □ Other
Name: [redacted] CALIF[ornia] Zip C[ode] [illegible] Address: [redacted] City: [illegible] Date of B[irth]: [illegible] Present A[ddress]: [illegible] City: [illegible] Zip Code [illegible] Phone: [illegible] [illegible] P.A.
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] Date: [illegible]
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) High School Attending Did Not Complete Graduated
College: Please give name of: Attending Advanced 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
City: LOS ANGELES Date of B[irth]: [illegible] Present Address: [illegible] City: [illegible] Zip Co[de]: [illegible] Phone: [illegible] [illegible]
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] Date: [illegible]
IMPORTANT -- AFTER READING, SIGNING AND DATING THIS SIDE -- TURN FORM OVER -- READ AND COMPLETE OTHER SIDE
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DB Cooper-23246
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b6 b7C
ADULT [REDACTED] ISTRATION FORM
Check Only One Please) High School Attending D & Not Complete Graduated
College: If none give name of: Attending Attended Graduates
Other
How did you learn of this center? (Check Only One, [illegible]) "A Sport Is Born" Movie Magazine Article Sports Show [illegible] Yellow Pages Ad World Championship 1962 Friend (Name) Word of Mouth Lecture Other
HOW DID YOU TRAVEL TO CENTER? [illegible] Bus Other
MEDICAL STATEMENT FOR UNDERGOING PARACHUTE TRAINING AND JUMPING I [illegible] 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 normal vision or have corrective lenses, and that I have [illegible]
Name: [REDACTED] CALIF [guess: address] [REDACTED] Age: [REDACTED] Wt [REDACTED] Ht [REDACTED] [REDACTED] Date of Birth: [REDACTED] Present Address: [REDACTED] City: [REDACTED] CALIF Zip Code: [REDACTED] Phone: [REDACTED]
1.3 Cardiac or pulmonary condition or disease 5.) Nervous disorder 2.) [illegible] or how [illegible] of [illegible] 6.) Diabetes 3.) Recurring spells or convulsions 7.) Kidney or related diseases 4.) History of fainting
Date: 9/10/71
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PARACHUTING CENTER
ADULT REGISTRATION FORM
Check Only One Please) High School: Attending D & Not Complete Graduated
College: Please give name of: Attending Attended Graduated
Other
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 Champio[nship] [illegible] X Friend (Name) [REDACTED] Word of Mouth Lecture Other
HOW DID YOU TRAVEL TO CENTER? Plane X Car Bus Other [illegible]
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 normal vision or have corrective lenses, and that I have [illegible]
Name: [REDACTED] CALIF [REDACTED] Age: [REDACTED] Weight/Ht: [REDACTED] Occupation: [REDACTED] Date of Birth: [REDACTED] Present Address: [REDACTED] City: [REDACTED] CALIF Zip Code: [REDACTED] Phone: [REDACTED] USPA: [REDACTED]
1.) Cardiac or pulmonary condition or disease 5.) Nervous disorder 2.) [illegible] or how [illegible] of pressure 6.) Diabetes 3.) Recurring spells or convulsions 7.) Kidney or related diseases 4.) History of fainting
Date: 9/10/71
---
DB Cooper-23247
---
b6 b7C
[illegible] ADULT [redacted] ATTENTION . [illegible] Date Only D [illegible] [illegible] [illegible] cafe [illegible] [multiple redacted blocks - b6, b7C] [illegible] Community [illegible] [illegible] [illegible] contact [illegible] [illegible] marks [illegible] [illegible] [illegible] and [illegible] — [illegible] [illegible] [illegible]
[illegible] W [illegible] 10 [illegible] of [illegible] [illegible] [illegible]
---
ABSOLUTE IDENTIFICATION FORM
Check Only One Please How did you learn of [us] (Check Only One, [illegible]) [illegible] [illegible] ☐ "A Spirit Is [guess: Coming]" [illegible] [illegible] Coupon[s] ☐ Report to [illegible] [illegible] [illegible] ☐ Colins Show [illegible] Only if [illegible] give name of[illegible] ☐ Review [guess: Paper] [illegible] [illegible] [illegible] ☐ [guess: World] Court [illegible] [guess: directly] [illegible] [illegible] [illegible] [illegible] ☐ Found [guess: Notice] — [illegible] [illegible] ☐ Word of Mouth O[illegible] . O[illegible]
HOW DO YOU WANT TO CONTACT? ☐ Phone ☐ Car ☐ Bus ☐ Other [illegible]
---
ADJUSTMENTS OR INCOMPLETE TRANSACTIONS AND COMPANIES [illegible] [illegible] [illegible] if for any physical information or chronic ail[ments] [illegible] [illegible] [illegible] [illegible] [illegible] or have corrective lenses, and that I have [illegible] [illegible] [illegible] [illegible]
[illegible] [illegible] [illegible] [illegible] [illegible] [illegible] [illegible]
(a) Nervous disorder (b) Diabetes (c) Kidney or related diseases
Date 3 - 1 - 71 [illegible]
[illegible] 5 [guess: Staff] — [illegible] [guess: four] [illegible] — READ AND COMPLETE ON [illegible]
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DB Cooper-23248
PARACHUTING CENTER ADULT REGISTRATION FORM
[Form fields, left side:] Pres [illegible] Corl _______ Cal ______ erpir _______ [illegible] Coupon On _______ Date of [illegible] _______ Person Address _______ City _______ [illegible] _______ Zip [illegible] [illegible]
[Form fields, right side:] How did you learn of the center? [Checkboxes:] - Only Own Personal A [guess: Sport] or [guess: Skydive] Movie - [illegible] for Article - [guess: Show] Vehicle - [guess: Yellow] Pages Ad - World Championship 1962 - [illegible] Tourism - Word of Mouth - [illegible] - Other
HOW DID YOU TRAVEL TO CENTER? [illegible] Bus [illegible] Other
MEDICAL STATEMENT FOR UNDERGOING PARACHUTE TRAINING AND JUMPING
I hereby certify that I am not now, nor have at any time been, under treatment for any physical infirmity or chronic ailment, 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. Bone or bone [guess: blood] problems 6. Diabetes 3. Fainting spells or convulsions 7. Kidney or related diseases 4. [illegible]
Date: [illegible] / /
SIGN -- TURN FORM OVER -- READ AND COMPLETE OTHER SIDE -- [illegible]
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PARACHUTING CENTER ADULT REGISTRATION FORM
[Form fields, left side:] [illegible] Cal [illegible]
[Form fields, right side:] How did you learn of the center? [Checkboxes:] - Only Own Personal A [guess: Sport] or [guess: Skydive] Movie [illegible] for Article [guess: Show] Vehicle [guess: Yellow] Pages Ad World Championship 1962 [illegible] Tourism Word of Mouth [illegible] Other
HOW DID YOU TRAVEL TO CENTER? Plane Car Bus Other
MEDICAL STATEMENT FOR UNDERGOING PARACHUTE TRAINING AND JUMPING
I voluntarily certify that I am not now, nor have at any time been, under treatment for any physical infirmity or chronic ailment, 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. Bone or bone [guess: blood] problems 6. Diabetes 3. Fainting spells or convulsions 7. Kidney or related diseases 4. Proof of [illegible]
Date: [illegible]
SIGN -- FIRST READ AND UNDERSTAND AND HAVING THIS SIDE -- TURN FORM OVER -- READ AND COMPLETE
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DB Cooper-23249
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b6 b7C
PARACHUT[ING] CENTER ADULT R[EGI]STRATION FOR[M]
Check Only One Please High School __ Attending __ Do Not Comp[lete]; [illegible] __ Graduated
College, Please give name of __ Attending __ Attended __ Graduation
How did you le[arn] (Check Only On[e]) __ "A Sport Is Bo[rn]" __ Magazine Art[icle] __ Sports Show W[alk] [illegible] Yellow Pages Ad __ World Champi[on] __ Friend (Name) __ Word of Mouth __ [L]ecture
Other __
HOW DID YOU TRAVEL TO CENTER? [illegible] Plane S-Car [illegible] Bus __ Other
MEDICAL STAT[EMENT] [FOR] UNDERGOING PARACHUTE TRAINING AND JUMPING
I hereby certify th[at I am] not [illegible] [and am] not under treatment for any physical infirmity or chronic ail- [ment] [illegible] or [illness] of any nature, and [that] I have normal [vision] or have corrective lenses, and that I have [illegible] [illegible] [illegible]
[Form fields for personal information - redacted with b6, b7C blocks] Name [REDACTED] Age [REDACTED] Date [REDACTED] Height Occupation [REDACTED] Date of Birth [REDACTED] Sex Present Address [REDACTED] City __ State Phone [REDACTED]
1) [illegible] education 2) [illegible] [illegible] 3) [illegible]
5) [illegible] disorders 6) Fractures 7) History of related diseases
---
PARACHUTING CENTER ADULT REGISTRATION FORM
Check Only One Pleas[e] High School __ Attending __ Did Not Complete __ Graduated
College, Please give name of __ Attending __ Attended __ Graduat[ed]
How did you learn [about] (Check Only One) __ "A Sport Is Born" [?] __ Magazine Article __ Sports Show Walk __ Yellow Pages Ad __ World Champions __ Friend (Name) __ __ Word of Mouth __ Lecture
Other
HOW DID YOU TRAVEL TO CENTER? Plane __ Car __ [illegible] Other
MEDICAL STATEMENT FOR UNDERGOING PARACHUTE TRAINING AND JUMPING
I hereby certify th[at I] [am] [in good] [health] and am not under treatment for any [physical] infirmity or chronic ail- ment, or [illness] of any nature, and [that] I have normal [vision] or have [corrective] lenses, and that I have [illegible]
[Form fields - redacted with b6, b7C blocks] S [illegible] Date [REDACTED] Occupation [REDACTED]
1) Care of or [pulmonary] [illegible] or [illegible] 2) [illegible] or [illegible] [illegible] 3) [illegible] [for] [illegible] 4) [illegible] [illegible] [illegible] DAT[E] [REDACTED]
PATIENT — AFTER READING, SIGN AND DATE EATING THIS [HALF] [illegible] [illegible] [illegible]
RIGHT FORM OVER
READ AND COMPLY.
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DB Cooper-23250
PARACHUTING CENTER ADULT REGISTRATION FORM
Print/cut Adults
[blank] Name CAUF [illegible] Color [blank] [blank] Weight [illegible] Height [blank]
Occupation [blank]
Date of Birth [blank] Sex [blank] MONTH [blank] YEAR [blank]
Present Address [illegible]
City [blank] State [blank] Zip Code [blank]
Phone [blank]
Check Only One Please: High School _ Attending _ Did Not Complete _ Graduated
College, Course and number of _ Attending _ Attended [illegible] Graduated
Other [blank]
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 [illegible] Other [blank]
HOW DID YOU TRAVEL TO CENTER? _ Car _ [illegible] _ [illegible] _ Other
MEDICAL STATEMENT FOR UNDERGOING PARACHUTE TRAINING AND JUMPING
I hereby certify that I am not aware of any physical or mental condition, either past or present, nor under treatment for any physical infirmity or chronic ailment, of any of the following, and I have not been treated, nor only of the following: and that I have never been treated to any of the following:
1. Cards or pulmonary conditions or [illegible] 5. Nervous disorder 2. High or low blood pressure 6. Diabetes 3. [illegible] or [illegible] 7. [illegible] or related diseases 4. [illegible] of [illegible]
Signature [blank] Date [blank]
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
[Duplicate of top form with same fields and layout]
City [blank] Prof [blank] Occupation [blank] Date of Birth [blank]
Present Address [blank] City [blank] State [blank] Zip Code [blank] Phone [blank] U S P A
Check Only One Please: High School _ Attending _ Did Not Complete _ Graduated
[Same educational and center discovery fields as top form]
MEDICAL STATEMENT FOR UNDERGOING PARACHUTE TRAINING AND JUMPING
[Same medical statement text as top form]
1. Cardiac or even emergencies or disease 5. Nervous disorder 2. High or low blood pressure or circulation 6. Diabetes 3. Fainting spells or seizures 7. Kidney or related diseases 4. [illegible] of [illegible]
DATE [blank]
IMPORTANT -- AFTER READING, SIGNING AND DATING THIS SIDE TURN FORM OVER -- READ AND COMPLETE OTHER SIDE
---
DB Cooper-23251
---
b6 b7C
ADULT [emblem] REGISTRATION· FORM
PARACHUTING CENTER
ADULT REGISTRATION FORM
[Handwritten entries in fields, partially illegible]
C.[illegible] N/Y Name [illegible] Age [illegible] Occupation [illegible] Date of Birth [illegible] Present Address [illegible]
City State [illegible] Phone [illegible] [illegible]
(Check Only One Please) How did you learn of this center? High School (Check Only One Please) Attending A Sport is Born Movie Do Not Complete Magazine Article Completed Sports Show Which Yellow Pages Ad College, Please give name of: World Championship 19[illegible] Attending Friend (Name) Attended Word of Mouth Graduated Instructor Other Given
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 an [illegible] and not under treatment for any physical infirmity or chronic ail- ment, or infirmity of any nature, and I [illegible] 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.) Here at [illegible]
Date [handwritten: illegible]
IMPORTANT -- AFTER READING, SIGNING AND DATING THIS SIDE -- TURN FORM OVER -- READ AND COMPLETE OTHER
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PARACHUTING CENTER
ADULT REGISTRATION FORM
[Handwritten entries in fields, partially illegible]
Name [illegible] N/[illegible] Age [illegible] [illegible] Occupation [illegible] Date of Birth [illegible] Present Address [illegible]
City [illegible] State Zip Code Phone [illegible] [illegible]
(Check Only One Please) How did you learn of this center? (Check Only One Please) High School A Sport is Born Movie Attending Magazine Article Do Not Complete Sports Show (Which) Completed Yellow Pages Ad World Championship 1982 College, Please give name of: Friend (Name) Attending Word of Mouth Attended Instructor Graduated Other
Given
HOW DID YOU TRAVEL TO CENTER? Car Bus Other
MEDICAL STATEMENT FOR UNDERGOING PARACHUTE TRAINING AND JUMPING
I hereby certify that I am not an [illegible] and not under treatment for any physical infirmity or chronic ail- ment, or infirmity of any nature, and I [illegible] 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.) [guess: Nervous] disorder 2.) High or low blood pressure 6.) Diabetes 3.) Fainting spells or convulsions 7.) Kidney or related diseases 4.) [illegible]
Signature [illegible] Date [handwritten: illegible]
IMPORTANT -- AFTER READING, SIGNING AND DATING THIS SIDE -- TURN FORM OVER -- READ AND COMPLETE OTHER SIDE
---
b6 b7C
DB Cooper-23252
[redacted] [redacted] Middle Initial Permanent Address
ADULT REGISTRATION FORM (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 this center? (Check Only One Please) ( ) "A Sport is Born" Movie ( ) Magazine Article ( ) Sports Show (Which) ( ) Yellow Pages Ad ( ) World Champi[onship] [redacted] ( ) Friend (Name) ( ) Word of Mouth ( ) Lecture Other
HOW DID YOU TRAVEL TO CENTER? ( ) Plane ( ) Car Bus ( ) Other
Age [redacted] Weight /[guess: 150] Height 5'[redacted] Occupation Date of Birth Sex M Present Address [redacted] City State Zip Code Phone S F A
---
MEDICAL STATEMENT FOR UNDERGOING PARACHUTE TRAINING AND JUMPING
I hereby certify that I am [guess: not] in [guess: ill] and [guess: am] not under treatment for any physical infirmity or chronic ail- ment, or injury of any nature, and I [guess: at] I have [guess: normal] vision or have corrective lenses, and that I have never been treated for any [guess: of] the following.
1. Cardiac or pulmonary com[guess: plain]t [guess: or] disease 5. Nervous disorder 2. High or low blood pressure 6. Seizures 3. Fainting [guess: spells] or [guess: convulsions] 7. Kidney or related diseases 4. [guess: Hernia] or [illegible]
---
Signature [redacted] Date [redacted]
IMPORTANT -- AFTER READING, SIGN AND BRING THIS SIDE
TURN FORM OVER -- READ AND COMPLETE OTHER SIDE
---
DB Cooper-23253
---
b6 b7C
Serials: 23248