OLIMPIADE OLAHRAGA SISWA NASIONAL (O2SN) SMP

TINGKAT KABUPATEN SUBANG TH. 2014

3x4 Foto
Berwarna

IDNTITAS PESERTA ATLET

Cabang Olahraga

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

KONTINGEN KECAMATAN

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

4 Buah

1. Nama Lengkap

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

2. Jenis Kelamin

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

3. Tempat/Tgl Lahir

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

4. Agama

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

5. Kelas

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

6. Nama Sekolah

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

Alamat Sekolah

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

7. Nama Kepala Sekolah

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

8. Alamat Rumah

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

- Kabupaten/Kota

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

- Kecamatan

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

- Kelurahan/Desa

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- No. Tlpn/HP

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9. Nama Orang Tua/Wali

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10. Pekerjaan Orang Tua/Wali

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

11. Alamat Orang Tua/Wali

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

12. Tinggi Dan Berat Badan

: .................Cm

:.......................Kg

Patokbeusi,

Maret 2014

Mengetahui,
Kepala Sekolah SMPN 2 Patokbeusi

KARSONO, S.Pd, M.M.Pd

Peserta/Atlet