Part 17, page 310

Transcript

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

PARACHUTING CENTER ADULT REGISTRATION FORM

Last Name: [blank] First: [blank] 1 Per[sonal] info: [partially illegible] Cal S[ex]: [blank] [blank] Age: [blank] Address: [blank]

Categor[y]: [blank] Date of birth: [blank] Alternate: [blank] Date of birth: [blank] Present Address: [blank]

City: State: a [or] Calif[ornia]

Pr[ior] [jump experience]: [blank]

How did you learn of the center? [ ] Only One Please [ ] A Friend or [Guest] Movie [ ] Newspaper Article [ ] Yellow [Pages] [ ] Yellow Pages Ad [ ] World Championship 1962 [ ] Friends Neighbor [ ] Word of Mouth [ ] Lecture [ ] Other

HOW DID YOU TRAVEL TO CENTER? [Phone] [or] [Car] [blank] Other

Date: [partially visible, possibly 4/7/ ]

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MEDICAL STATEMENT FOR UNDERGOING PARACHUTE TRAINING AND JUMPING

I here[by] certify that I am [aware of the] [risks] and am not under treatment for any physical infirmity or chronic ail- ments, or infirm[ity] 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.) Carbuncle or pulmonary condition or disease 2.) Night or low blood pressure 3.) Fainting spells or convulsions 4.) Period of hearing [loss] 5.) Nervous disorder 6.) Diabetes 7.) Kidney or related diseases

Date: [partially visible]

[illegible line] -- TURN FORM OVER -- READ AND COMPLETE O[THER SIDE]

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PARACHUTING CENTER ADULT REGISTRATION FORM

Last Name: [blank] [blank] Cal [blank fields]

Date of [birth]: [blank] Date of birth: [blank]

City: [blank] [blank]

How did you learn of the center? [ ] Only One P[lease] [ ] [blank] O[nly] One P. A [Friend] & [Guest] Mo[vie] N[ewspaper] Article [ ] Yellow Pages Ad [ ] World Champ[ionship] [ ] Friends Neighb[or] [ ] Word of Mouth [ ] [L]ecture [ ] Other

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

College: [blank] [or other]: [blank] Alt[ernate]: [blank] Approved: [blank] [Qual]ified: [blank]

Group: [blank]

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MEDICAL STATEMENT FOR UNDERGOING PARACHUTE TRAINING AND JUMPING

I here[by] certify that I am [aware of] and am not under treatment for any physical infirmity or chronic ail- ments, or infirm[ity] 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.) Carbuncle or pulmonary condition or disease 2.) [blank] or low blood pressure 3.) Fainting [spells] or convulsions 4.) Period of hearing [loss] 5.) Nervous disorder 6.1 Diabetes 7.) Kidney or related diseases

Date: [partially visible]

[illegible] -- TURN FORM OVER -- READ AND COMPLETE O[THER SIDE] [text partially illegible at bottom]

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b6 b7C

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DB Cooper-5140