SEKOLAH SEPAK BOLA MANDIRI (SSBM)

BOJONG INDAH
Sekretariat : Jl. H. Mawi Gg. Parung Hansip RT. 06/03 Bojong Indah
Kec. Parung Kab. Bogor - 0856-9761-0499 0856-9103-9138

FORMULIR PENDAFTARAN SISWA :

KELAS / KELOMPOK*) : A B C D NOMOR INDUK*) :

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Tempat, Tanggal Lahir : ..................................................................................................................
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Pekerjaan : ..................................................................................................................
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Nomor Telepon : ..................................................................................................................
Nama Sekolah : .................................................................................................................
Alamat Sekolah : ..................................................................................................................
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Golongan Darah : O A B AB
Tinggi Badan : Cm.
Berat Badan : Kg.
Penyakit kronis yang pernah/sedang diderita (satu tahun terakhir) :
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Mengetahui dan menyetujui, Bogor, .................................................

Orang Tua / Wali, Siswa,

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Tanda tangan dan nama jelas Tanda tangan dan nama jelas

Catatan :
* Diisi oleh pengurus