FORMULIR PENDAFTARAN

FORMULIR PENDAFTARAN

Saya Yang Bertanda Tangan Di Bawah Ini,

Mohon Untuk Dapat Diterima Sebagai Siswa Dan Mengikuti Latihan Pencak Silat Persaudaraan Setia Hati Terate Rayon Griya Asri Taman Mini.

Untuk Itu Saya Sanggup Memenuhi Persyaratan Yang Di Tentukan Serta Akan Mentaati Segala Peraturan Yang Ada Dalam Lingkungan Persaudaraan Setia Hati Terate Griya Asri Taman Mini.

I.     DATA PRIBADI

Nama Lengkap                   : ........................................................................................................

Tempat Tanggal Lahir        : ........................................................................................................

Jenis Kelamin                     : ........................................................................................................

Pendidikan                          : ........................................................................................................

Pekerjaan                           : ........................................................................................................

Alamat                                : ........................................................................................................

No. Telp./Handphone         : ........................................................................................................

Tinggi,Berat Badan            : ........................................................................................................

Golongan Darah                 : A / B / O / AB

Pernah Mengikuti Beladiri : ........................................................................................................

(Jika Punya Jelaskan)            ........................................................................................................

II.  DATA ORANG TUA WALI

1.      Nama Bapak Kandung : ........................................................................................................

Tempat,Tanggal Lahir : ........................................................................................................

Pekerjaan                     : ........................................................................................................

2.      Nama Ibu Kandung       : ........................................................................................................

Tempat,Tanggal Lahir : ........................................................................................................

Pekerjaan                     : ........................................................................................................

Alamat                          : ........................................................................................................

No.Phone/Telp            : ........................................................................................................