Part 55, page 103

Transcript

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

ADULT REGISTRATION FORM (Check Only One Please) High School [illegible] Attending Did Not Complete Graduated

College: Please give name of: Attending Attended Graduated

Other

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 ____

HOW DID YOU TRAVEL TO CENTER? □ Plane □ Car □ Bus □ Other

Name: [redacted] CALIF[ornia] Zip C[ode] [illegible] Address: [redacted] City: [illegible] Date of B[irth]: [illegible] Present A[ddress]: [illegible] City: [illegible] Zip Code [illegible] Phone: [illegible] [illegible] P.A.

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 ail- ment, or injury 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. 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. Hard of hearing

Signature: [illegible] Date: [illegible]

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) High School Attending Did Not Complete Graduated

College: Please give name of: Attending Advanced Graduated

Other ____

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 ____

HOW DID YOU TRAVEL TO CENTER? □ Plane □ Car □ Bus □ Other

City: LOS ANGELES Date of B[irth]: [illegible] Present Address: [illegible] City: [illegible] Zip Co[de]: [illegible] Phone: [illegible] [illegible]

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 ail- ment, or injury 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. 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. Hard of hearing

Signature: [illegible] Date: [illegible]

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

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DB Cooper-23246

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b6 b7C