Part 55, page 104

Transcript

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

ADULT [REDACTED] ISTRATION FORM

Check Only One Please) High School Attending D & Not Complete Graduated

College: If none give name of: Attending Attended Graduates

Other

How did you learn of this center? (Check Only One, [illegible]) "A Sport Is Born" Movie Magazine Article Sports Show [illegible] Yellow Pages Ad World Championship 1962 Friend (Name) Word of Mouth Lecture Other

HOW DID YOU TRAVEL TO CENTER? [illegible] Bus Other

MEDICAL STATEMENT FOR UNDERGOING PARACHUTE TRAINING AND JUMPING I [illegible] 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 normal vision or have corrective lenses, and that I have [illegible]

Name: [REDACTED] CALIF [guess: address] [REDACTED] Age: [REDACTED] Wt [REDACTED] Ht [REDACTED] [REDACTED] Date of Birth: [REDACTED] Present Address: [REDACTED] City: [REDACTED] CALIF Zip Code: [REDACTED] Phone: [REDACTED]

1.3 Cardiac or pulmonary condition or disease 5.) Nervous disorder 2.) [illegible] or how [illegible] of [illegible] 6.) Diabetes 3.) Recurring spells or convulsions 7.) Kidney or related diseases 4.) History of fainting

Date: 9/10/71

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PARACHUTING CENTER

ADULT REGISTRATION FORM

Check Only One Please) High School: Attending D & Not Complete Graduated

College: Please give name of: Attending Attended Graduated

Other

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 Champio[nship] [illegible] X Friend (Name) [REDACTED] Word of Mouth Lecture Other

HOW DID YOU TRAVEL TO CENTER? Plane X Car Bus Other [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 ailment, or injury of any nature, and that I have normal vision or have corrective lenses, and that I have [illegible]

Name: [REDACTED] CALIF [REDACTED] Age: [REDACTED] Weight/Ht: [REDACTED] Occupation: [REDACTED] Date of Birth: [REDACTED] Present Address: [REDACTED] City: [REDACTED] CALIF Zip Code: [REDACTED] Phone: [REDACTED] USPA: [REDACTED]

1.) Cardiac or pulmonary condition or disease 5.) Nervous disorder 2.) [illegible] or how [illegible] of pressure 6.) Diabetes 3.) Recurring spells or convulsions 7.) Kidney or related diseases 4.) History of fainting

Date: 9/10/71

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DB Cooper-23247

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b6 b7C