Part 17, page 314

Transcript

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

b6 b7C

---

ADULT REGISTRATION FORM

Permanent Address _______________ [redacted] State [guess: Cal] Zip Code ___ Phone ________ Age ___ Weight 150 Height 5' [illegible] Occupation _______________ Date of Birth ___________ Sex M Present Address . [guess: Same as above] [illegible] City ________ State ___ Zip Code ___ Phone ________ S P A

(Check Only One Please) High School: How did you learn of the center? [ ] Attending (Check Only One Please) [ ] Did Not Complete [ ] "A Sport is Born" Movie [✓] Graduated [ ] Magazine Article [ ] Sports Show (Which) College: Please give name of: [ ] Yellow Pages Ad [ ] Attending [✓] World Champion [illegible] [ ] Attended [✓] Friend (Name) [redacted] [ ] Graduated [ ] Word of Mouth [ ] Lecture Other ___ Other ___

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

---

MEDICAL STATEMENT FOR UNDERGOING PARACHUTE TRAINING AND JUMPING

"I hereby certify that I am not [guess: being] and am not under treatment for any physical infirmity or chronic ail- ment, or injury of any nature, and that I have [guess: 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.) Seizures 3.) Fainting spells or convulsions 7.) Kidney or related diseases 4.) None of [guess: the above]

Signature _______________ [signature present] [guess: 1/30/71]

---

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

---

DB Cooper-5144