Part 55, page 109

Transcript

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

ADULT [emblem] REGISTRATION· FORM

PARACHUTING CENTER

ADULT REGISTRATION FORM

[Handwritten entries in fields, partially illegible]

C.[illegible] N/Y Name [illegible] Age [illegible] Occupation [illegible] Date of Birth [illegible] Present Address [illegible]

City State [illegible] Phone [illegible] [illegible]

(Check Only One Please) How did you learn of this center? High School (Check Only One Please) Attending A Sport is Born Movie Do Not Complete Magazine Article Completed Sports Show Which Yellow Pages Ad College, Please give name of: World Championship 19[illegible] Attending Friend (Name) Attended Word of Mouth Graduated Instructor Other Given

HOW DID YOU TRAVEL TO CENTER? Plane Car Bus Other

MEDICAL STATEMENT FOR UNDERGOING PARACHUTE TRAINING AND JUMPING

I hereby certify that I am not an [illegible] and not under treatment for any physical infirmity or chronic ail- ment, or infirmity of any nature, and I [illegible] 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.) Here at [illegible]

Date [handwritten: illegible]

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

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PARACHUTING CENTER

ADULT REGISTRATION FORM

[Handwritten entries in fields, partially illegible]

Name [illegible] N/[illegible] Age [illegible] [illegible] Occupation [illegible] Date of Birth [illegible] Present Address [illegible]

City [illegible] State Zip Code Phone [illegible] [illegible]

(Check Only One Please) How did you learn of this center? (Check Only One Please) High School A Sport is Born Movie Attending Magazine Article Do Not Complete Sports Show (Which) Completed Yellow Pages Ad World Championship 1982 College, Please give name of: Friend (Name) Attending Word of Mouth Attended Instructor Graduated Other

Given

HOW DID YOU TRAVEL TO CENTER? Car Bus Other

MEDICAL STATEMENT FOR UNDERGOING PARACHUTE TRAINING AND JUMPING

I hereby certify that I am not an [illegible] and not under treatment for any physical infirmity or chronic ail- ment, or infirmity of any nature, and I [illegible] 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.) [guess: Nervous] disorder 2.) High or low blood pressure 6.) Diabetes 3.) Fainting spells or convulsions 7.) Kidney or related diseases 4.) [illegible]

Signature [illegible] Date [handwritten: illegible]

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

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b6 b7C

DB Cooper-23252