Part 64, page 403

Transcript

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

[Last Name] _____ [First Name] _____ [Middle Initial] _____

ADULT REGISTRATION FORM .Check Only One Pleas[e]

City _____ State/[Code] _____ Zip Code _____ High School Photo _____ Age _____ Weight /5[0] [illegible] [illegible] 1) Attending 2) Did Not Complete Occupation _____ 3) Graduated Date of Birth _____ Sex M College: Please give name of: Present Address [illegible handwriting] 1) Attending 2) Entered City _____ State _____ Zip Co[de] 3) [Graduated] Phone _____ Other

How did you learn of this course? (Check Only One Please) 1) "A Sport is Born" Movie 2) Magazine Article 3) Sports Show (Which) 4) Yellow Pages Ad 5) World Champ[ionship] 6) Friend (Name) _____ 7) Word of Mouth 8) Lecture Other

HOW DID YOU TRAVEL TO CENTER? b[us] X C[ar] [illegible] Other

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MEDICAL STATEMENT FOR UNCONDITIONAL PARACHUTE TRAINING AND JUMPING

I hereby certify that I am not [under] the [care] of [a] [physician] or [under] treatment for any physical infirmity or chronic ail- ment, or injury of any nature, or [that] [I] [have] [ever] [had] a [condition] [which] [or] [have] [ever] [had] corrective [devices], and that I have never been [refused] [or] [denied] [insurance] for any [illegible] [reason]

1) Cardiac or pulmonary condition or [disease] 2) High or low blood [pressure] 3) Fainting [spells] or [convulsive] [fits] 4) [Mental] or [emotional] [illegible]

5) Nervous disorder 6) [Diabetes] 7) [Bone] or related [disorders]

5. [signature]

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IMPORTANT -- AFTER READING, SIGN AND RETURN THIS SIDE TURN FORM OVER -- READ AND COMPLETE OTHER SIDE [illegible additional text]

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b6 b7C

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DB-Cooper-26853