Part 17, page 289

Transcript

The scan is the source; the transcript is machine-generated from it.

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

---

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

---

DB Cooper-5119