Part 17, page 296

Transcript

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

ADULT REGISTRATION FORM

Permanent Address: [redacted] State: [redacted] Zip Code: [blank] Phone: [blank] Age: [blank] Weight: 150 Height: 5' 7" Occupation: [blank] Date of Birth: [blank] DAY [blank] MONTH [blank] YEAR Sex: M Present Address: [guess: Burns Ave] [guess: 46904] City: [blank] State: [blank] Zip Code: [blank] Phone: [blank] S P A: [blank]

(Check Only One Please) High School: [ ] Attending [ ] Did Not Complete [ ] Graduated

College, Please give name of: [ ] Attending [ ] Attended [ ] Graduated Other: [blank]

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 [guess: 1974] [X] Friend (Name) [redacted] [ ] Word of Mouth [ ] Lecture [ ] Other

HOW DID YOU TRAVEL TO CENTER? [ ] Phone [X] Car [ ] Bus [ ] Other

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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 abnormal 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. Disorders of hearing

Signature: [redacted] Date: 1/24/71

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IMPORTANT -- AFTER READING, SIGNING AND DATING THIS SIDE TURN FORM OVER -- READ AND COMPLETE OTHER SIDE [illegible fine print line below]

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-76- DB Cooper-5126