Part 55, page 108

Transcript

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

PARACHUTING CENTER ADULT REGISTRATION FORM

Print/cut Adults

[blank] Name CAUF [illegible] Color [blank] [blank] Weight [illegible] Height [blank]

Occupation [blank]

Date of Birth [blank] Sex [blank] MONTH [blank] YEAR [blank]

Present Address [illegible]

City [blank] State [blank] Zip Code [blank]

Phone [blank]

Check Only One Please: High School _ Attending _ Did Not Complete _ Graduated

College, Course and number of _ Attending _ Attended [illegible] Graduated

Other [blank]

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 [illegible] Other [blank]

HOW DID YOU TRAVEL TO CENTER? _ Car _ [illegible] _ [illegible] _ Other

MEDICAL STATEMENT FOR UNDERGOING PARACHUTE TRAINING AND JUMPING

I hereby certify that I am not aware of any physical or mental condition, either past or present, nor under treatment for any physical infirmity or chronic ailment, of any of the following, and I have not been treated, nor only of the following: and that I have never been treated to any of the following:

1. Cards or pulmonary conditions or [illegible] 5. Nervous disorder 2. High or low blood pressure 6. Diabetes 3. [illegible] or [illegible] 7. [illegible] or related diseases 4. [illegible] of [illegible]

Signature [blank] Date [blank]

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

[Duplicate of top form with same fields and layout]

City [blank] Prof [blank] Occupation [blank] Date of Birth [blank]

Present Address [blank] City [blank] State [blank] Zip Code [blank] Phone [blank] U S P A

Check Only One Please: High School _ Attending _ Did Not Complete _ Graduated

[Same educational and center discovery fields as top form]

MEDICAL STATEMENT FOR UNDERGOING PARACHUTE TRAINING AND JUMPING

[Same medical statement text as top form]

1. Cardiac or even emergencies or disease 5. Nervous disorder 2. High or low blood pressure or circulation 6. Diabetes 3. Fainting spells or seizures 7. Kidney or related diseases 4. [illegible] of [illegible]

DATE [blank]

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

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DB Cooper-23251

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b6 b7C