Part 17, page 292

Transcript

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

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

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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