Part 17, page 294

Transcript

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

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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