Part 17, page 313

Transcript

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

ADULT REGISTRATION FORM

Check Only One Please High School Attending A Sport Is Born Movie Got Into Parachute Co-located

College, Please give name of: Attending Attended Graduated

Other

Personal information fields: C/Y ___ N.Y. Zip Code Phone ___ Age ___ Weight ___ Height ___ Occupation ___ Date of Birth ___ Present Address ___ City ___ State ___ Zip Code Phone ___

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 (Named) [ ] Word of Mouth [ ] Lecture [ ] Other

HOW DID YOU TRAVEL TO CENTER? : Private : Car : Bus : Other

MEDICAL STATEMENT FOR UNDERGOING PARACHUTE TRAINING AND JUMPING

I hereby certify that I am not aware of nor am I now under treatment for any physical infirmity or chronic ail- ment, or infirmity of any nature, and I [guess: also] 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.) [guess: Loss] of hearing

Date 4 / [illegible] / [illegible]

TURN FORM OVER - READ AND COMPLETE OTHER SIDE

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PARACHUTING CENTER ADULT REGISTRATION FORM

[Identical form structure to section 1]

Check Only One Please High School Attending Got Not Complete Graduated

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 (Named) [ ] Word of Mouth [ ] Lecture [ ] Other

HOW DID YOU TRAVEL TO CENTER? : Car : Bus : Other

MEDICAL STATEMENT FOR UNDERGOING PARACHUTE TRAINING AND JUMPING

I hereby certify that I am not aware of nor am I now under treatment for any physical infirmity or chronic ail- ment, or injury of any nature, and I [guess: also] 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.) [guess: Loss] of hearing

Signature ___

IMPORTANT -- AFTER READING, SIGNING AND DATING THIS SIDE -- TURN FORM OVER -- READ AND COMPLETE OTHER SIDE

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b6 b7C

DB Cooper-5143