FORMULIR PENDAFTARAN

KADER POSYANDU REMAJA NIBUNG

A. IDENTITAS CALON KADER
NAMA

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

JENIS KELAMIN

: Laki-laki/ Perempuan

TEMPAT/TANGGAL LAHIR : ...........................................................................

TINGGI BADAN

: .

BERAT BADAN

: .

AGAMA

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

KELAS/ASAL SEKOLAH

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

ALAMAT

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

NO TELP / HP

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

HOBBY

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

MOTIVASI JADI KADER

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

B. IDENTITAS ORANG TUA/WALI

NAMA

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

PEKERJAAN

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

NO TELP / HP

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

Mengetahui
Orang Tua/ Wali Calon Kader

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*Coret yang tidak perlu