Introductory Flight Record / Disclosure
Student Information
Student Name: ______________________________________________________________________________________________________________________________________________________
Address: ____________________________________________________________________________________________________________________________________________________________
Email: _______________________________________________________________________________________________________________________________________________________________
Phone Number: ______________________________________________________________________________________________________________________________________________________
Driver’s License: _____________________________________________________________________________________________________________________________________________________
Passport: ____________________________________________________________________________________________________________________________________________________________
Birth Certificate: ______________________________________________________________________________________________________________________________________________________
Student Pilot Certificate: ______________________________________________________________________________________________________________________________________________
Statements of Danger:
Captain Drake’s Flight School offers training in ultralight, light sport, and gyroplane aircraft. Participation carries significant risks, including but not limited to:
➤ Mechanical risks (engine/system failures, unplanned impacts)
⚠️ By participating, you acknowledge these risks and voluntarily accept them.
In consideration of the use of Captain Drake’s aircraft (N843AM, N65SS, N308SG, N912AF, etc.) and services provided by Jason B. Emonds or related entities, I (Print Name) _____________________, for myself, heirs, and assigns:
Signature: _________________________ Date: ____________
Training Milestones
8:00 AM - 8:00 PM