Part 55, page 110

Transcript

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

[redacted] [redacted] Middle Initial Permanent Address

ADULT REGISTRATION FORM (Check Only One Please)

High School: ( ) Attending ( ) Did 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 Champi[onship] [redacted] ( ) Friend (Name) ( ) Word of Mouth ( ) Lecture Other

HOW DID YOU TRAVEL TO CENTER? ( ) Plane ( ) Car Bus ( ) Other

Age [redacted] Weight /[guess: 150] Height 5'[redacted] Occupation Date of Birth Sex M Present Address [redacted] City State Zip Code Phone S F A

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MEDICAL STATEMENT FOR UNDERGOING PARACHUTE TRAINING AND JUMPING

I hereby certify that I am [guess: not] in [guess: ill] and [guess: am] not under treatment for any physical infirmity or chronic ail- ment, or injury of any nature, and I [guess: at] I have [guess: normal] vision or have corrective lenses, and that I have never been treated for any [guess: of] the following.

1. Cardiac or pulmonary com[guess: plain]t [guess: or] disease 5. Nervous disorder 2. High or low blood pressure 6. Seizures 3. Fainting [guess: spells] or [guess: convulsions] 7. Kidney or related diseases 4. [guess: Hernia] or [illegible]

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Signature [redacted] Date [redacted]

IMPORTANT -- AFTER READING, SIGN AND BRING THIS SIDE

TURN FORM OVER -- READ AND COMPLETE OTHER SIDE

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DB Cooper-23253

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b6 b7C