Part 17, page 290

Transcript

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

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