LEMBAR BUKU INDUK REGISTRASI Photo 3 x 4

PESERTA DIDIK

Nomor Induk Siswa : ....................................................

Nomor Tanda Anggota : ....................................................

A. KETERANGAN PRIBADI

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

Panggilan : ...............................................................

2. Jenis Kelamin : Pria / Wanita *)

3. Tempat dan tanggal lahir : ...............................................................

4. Agama : ...............................................................

5. Kewarga Negaraan : WNI / WNA Keturunan *)

6. Anak ke : ...............................................................

7. Jumlah saudara Kandung : ...............................................................

Tiri : ...............................................................

8. Bahasa sehari-hari dikeluarga : ...............................................................

9. Keadaan jasmani Tinggi Badan : ..................................................Cm

Berat Badan : ...................................................Kg

Golongan Darah : ...............................................................

10. A l a m a t : ...................................................................................................

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

11. Bertempat tinggal pada : Orang Tua / Menumpang / Asrama *)

Jarak Tempat tinggal ke

12. : ...................................................................................................
pangkalan

13. Perjalanan ke Panggkalan : Jalan Kaki / Naik Kendaraan *)

14. Minat / Bakat / Hobi : ...................................................................................................

Pengalaman Dalam
15. : ...................................................................................................
Kepramukaan
B. KETERANGAN ORANG TUA / WALI
1. Orang Tua Kandung ;
a. Ayah : .......................................................................................
b. Ibu : .......................................................................................
c. Umur Ayah / Ibu : ...................... th / ...................... th
d. Pendidikan Ayah / Ibu : .......................................... / ..........................................
e. Pekerjaan Ayah / Ibu : .......................................... / ..........................................

2. Wali ( Jika Mempunyai ) :

a. Nama : .......................................................................................
b. Hubungan Keluarga : .......................................................................................
c. Umur : ...................... th
d. Agama : .......................................................................................
e. Pendidkan / Pekerjaan : .......................................... / ..........................................

C. PERKEMBANGAN KEANGGOTAAN :

1. Keanggotaan Sebelumnya
a. Masuk menjadi Anggota Baru / Pangkalan / Gugus Depan ;
- Diterima Tanggal : .......................................................................................
- Di Golongan / Tingkat : .......................................................................................
b. Pindahan dari Pangkalan / Gugus Depan Lain
- Nama Pangkalan / Gugus Depan : .......................................................................................
- Dari Golongan / Tigkat : .......................................................................................

2. Perkembangan Keadaan Jasmani :

a. Tahun

b. Berat Badan Kg Kg Kg Kg Kg Kg

c. Tinggi Badan Cm Cm Cm Cm Cm Cm

d. Penyakit Yang diidap

e. Kelainan Jasmani

D. LAIN – LAIN
Catatan Penting lainnya :
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