GERAKAN PRAMUKA

GUDEP 01005 01006 KOTA BANDUNG

PANGKALAN SMA LAB. SCHOOL UPI
Jl. Senjayaguru Kampus UPI Tlp. (022)2004404 Bandung (40154)
Website: sma.labschool.upi.edu E-mail: Sma_labschool@upi.edu

FORMULIR PENDAFTARAN
A. Identitas Diri
Nama Lengkap
Nama Panggilan
NIS
TTL
Agama
Alamat Asal
Alamat Sekarang
Alamat Email
No. Kontak
B. Identitas Keluarga
Orang Tua/Wali
1. Nama ayah
Pekerjaan
Alamat
2. Nama Ibu
Pekerjaan
Alamat
Saudara Kandung
C. Riwayat Pendidikan
SD/MI
SMP/MTS
SMA
D. Riwayat Kepramukaan
SIAGA
PENGGALANG

: ...............................................................................
: ..............................................................................
: ......................................
: ...............................................................................
: ..............................................................................
: ..............................................................................
: ..............................................................................
: ..............................................................................
: .............................................................................

Jenis Kelamin : L/P

Photo
2x3

: ..............................................................................
: ..............................................................................
: ..............................................................................
: ..............................................................................
: ..............................................................................
: ..............................................................................
: Jumlah Kakak : ................... Jumlah Adik : .....................
: .................................................................................... Lulus Tahun : ..............
: .................................................................................... Lulus Tahun : ..............
: .................................................................................... KELAS X : ..............
: ................................................Tahun : ...................... Jabatan : ...........................
: ................................................Tahun : ...................... Jabatan : ...........................

E. Prestasi yang pernah diraih

1. .................................................................................................... 4...............................................................................
2. .................................................................................................... 5..............................................................................
3. .................................................................................................... 6..............................................................................
F. Organisasi yang pernah diikuti
1. .................................................................................................... 4..............................................................................
2. .................................................................................................... 5..............................................................................
3. .................................................................................................... 6..............................................................................
G. Motivasi Masuk Pramuka
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Bandung,
Agustus 201
Pendaftar,

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GERAKAN PRAMUKA
GUDEP 01005 01006 KOTA BANDUNG
PANGKALAN SMA LAB. SCHOOL UPI
Jl. Senjayaguru Kampus UPI Tlp. (022)2004404 Bandung (40154)
Website: sma.labschool.upi.edu E-mail: Sma_labschool@upi.edu