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Hari : ............................ Tanggal : ............................................. Hari : ............................ Tanggal : .............................................

Shalat Pelaksanaan Shalat Pelaksanaan


Fardhu B M T Tarawih : Ya / Tidak Fardhu B M T Tarawih : Ya / Tidak
Shubuh Makan Sahur : Ya / Tidak Shubuh Makan Sahur : Ya / Tidak
Dzuhur Puasa Hari Ini : Tamat / Tidak Dzuhur Puasa Hari Ini : Tamat / Tidak
Ashar Alasan : .............................. Ashar Alasan : ..............................
Magrib Tadarus, Surat : .............................. Magrib Tadarus, Surat : ..............................
Isya Ayat : ............ s/d ............ Isya Ayat : ............ s/d ............

Ceramah : Secara langsung / Radio /TV/ Media Cetak Ceramah : Secara langsung / Radio /TV/ Media Cetak
Penceramah : .................................................................................................................................................... Penceramah : ....................................................................................................................................................
Tempat/Media : .................................................................................................................................................... Tempat/Media : ....................................................................................................................................................
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Mengetahui Mengetahui
Orang Tua/Wali Penceramah / Imam Orang Tua/Wali Penceramah / Imam

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Hari : ............................ Tanggal : ............................................. Hari : ............................ Tanggal : .............................................


Shalat Pelaksanaan Shalat Pelaksanaan
Fardhu B M T Tarawih : Ya / Tidak Fardhu B M T Tarawih : Ya / Tidak
Shubuh Makan Sahur : Ya / Tidak Shubuh Makan Sahur : Ya / Tidak
Dzuhur Puasa Hari Ini : Tamat / Tidak Dzuhur Puasa Hari Ini : Tamat / Tidak
Ashar Alasan : .............................. Ashar Alasan : ..............................
Magrib Tadarus, Surat : .............................. Magrib Tadarus, Surat : ..............................
Isya Ayat : ............ s/d ............ Isya Ayat : ............ s/d ............

Ceramah : Secara langsung / Radio /TV/ Media Cetak Ceramah : Secara langsung / Radio /TV/ Media Cetak
Penceramah : .................................................................................................................................................... Penceramah : ....................................................................................................................................................
Tempat/Media : .................................................................................................................................................... Tempat/Media : ....................................................................................................................................................
............................................................................................................................................................................... ...............................................................................................................................................................................
............................................................................................................................................................................... ...............................................................................................................................................................................
............................................................................................................................................................................... ...............................................................................................................................................................................
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Mengetahui Mengetahui
Orang Tua/Wali Penceramah / Imam Orang Tua/Wali Penceramah / Imam

.......................... .......................... .......................... ..........................

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