Discovery Flight - CPC Kit Information

This form is to be filled out prior to the discovery flight by the instructor. This contains contact info for the person that will be on the flight.

Instructor: *

 

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Participant Info:

First Name: *

Last Name: *

Address: *

Apt:

Address 2:

City: *

State: *

Zip: *

Home Phone:

Alternate Phone:

Email:

Govt ID - State and Number: *

Birth Date: *

 

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Additional Contact Person:

Additional Contact - First Name:

Last Name:

Address:

Address 2:

Apt:

City:

State:

Zip:

Home Phone:

Alternate Phone:

Relationship:

Notes:

What code is in the image?: *

Enter the characters shown in the image.