FORM PERIJINAN MADRASAH

 NAMA MADRASAH : MTs AL-HAMIDIYAH

 ALAMAT : Jl. RAYA PUTAT LOR GONDANGLEGI

 TELEPON/FAX : 0341 879793

 KODE POS : 65174

Dengan ini menyatakan keikutsertaan siswanya untuk mengikuti Gelar Lomba-lomba Pramuka
Madrasah “GELORA MADRASAH” 2017 yang diadakan oleh Sako Gerakan Pramuka Kemenag Kwarcab
Malang, dengan daftar nama sebagai berikut:

NO NAMA LENGKAP JABATAN

1 Pembina Damping
2 Ketua
3 Wakil
4 Anggota
5 Anggota
6 Anggota
7 Anggota
8 Anggota
9 Anggota
10 Anggota
11 Anggota

Malang, 23 Agustus 2017

Mengetahui

Kepala Madrasah / KAMABIGUS,

Drs. H. Syahid Syahroni

 FORMULIR PENDAFTARAN PESERTA

 Kwartir Ranting : .................................................................................................

 Gugus Depan : .................................................................................................

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

 Tempat, tanggal & lahir : .................................................................................................

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

 Agama : .................................................................................................

 Gol. Darah : .................................................................................................

 Alamat : .................................................................................................

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

 Handphone : .................................................................................................

 Nama Orang Tua : ..................................................................................................

 Pekerjaan : ..................................................................................................

 Alamat Orang Tua : ..................................................................................................

Malang, ........................................2017

Mengetahui

Orang Tua Ketua Gugus Depan ……………….. Peserta

(_____________________) ( ) (_____________________)
 FORMULIR PERIJINAN ORANG TUA

Saya yang bertanda tangan di bawah ini,

Nama Ayah / Ibu : ..................................................................................................

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

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

Telepon / HP Ayah : ..................................................................................................

Telepon/Hp Ibu : ..................................................................................................

Kode Pos : ..................................................................................................

Dengan ini kami selaku orang tua mengizinkan putra/putri kami tersebut :

Nama : ..................................................................................................

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

Telepon : ..................................................................................................

Madrasah : ..................................................................................................

untuk mengikuti Gelar Lomba-lomba Pramuka (GELORA) Madrasah yang diadakan oleh Sako
Gerakan Pramuka Kementerian Agama Kab. Malang, serta bersedia mematuhi segala aturan yang
di tentukan oleh penyelenggara.

..............., ................................

Mengetahui

(_______________________)

Orang Tua

Note : Form ini di copy sejumlah anggota regu

 FORMULIR PENDAFTARAN PEMBINA DAMPING

Kwartir Ranting : .................................................................................................

Gugus Depan : .................................................................................................

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

Tempat, tanggal & lahir : .................................................................................................

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

Agama : .................................................................................................

Gol. Darah : .................................................................................................

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

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

Tlp. Rumah/Handphone : ..................................................................................................

Pengalaman pembina : .......................................................................................Tahun

KMD Tahun : .................... …. Di ...................................................................

KML Tahun : .................... …. Di ...................................................................

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

.................,......................................

Pembina

(______________________________)

Mengetahui,

Ketua Kwarran ………..………………… Ketua Mabigus ……………………………….……..

( ) (_______________________________)