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FORMULIR PENDAFTARAN

PROGRAM YANG DIPILIH ( pilih salah satu )

 SD
 SMP
 ENGLISH COURSE

DATA SISWA

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

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

Tempat, Tanggal Lahir : ...........................................,....../............../.............................../................

Jenis Kelamin : Laki – Laki / Perempuan

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

Asal Sekolah : ..........................................................................Kelas...............................

No. Telepon / HP : ..................................................................................................................

DATA ORANGTUA

Nama Ayah : ..................................................................................................................

Nama Ibu : ..................................................................................................................

No. Telepon / HP Ayah : ..................................................................................................................

No. Telepon / HP Ibu : ..................................................................................................................

TAMBAHAN

Kendala Yang Dihadapi Oleh siswa :

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