FORM.

01
JAMBORE MI 2019

BIODATA PESERTA JAMBORE MI 2019

Nama Regu : .......................................................................................................................

Nomor / Nama Gudep : .......................................................................................................................
Pangkalan / Madrasah : .......................................................................................................................
Kwartir Ranting : .......................................................................................................................
Kwartir Cabang : .......................................................................................................................

I. UMUM
Nama : .......................................................................................................................
Tempat, Tgl. Lahir : .......................................................................................................................
NTA : .......................................................................................................................
Hobby : .......................................................................................................................
Cita-Cita : .......................................................................................................................
Telp/HP : .......................................................................................................................
Alamat : .......................................................................................................................

II. KEPRAMUKAAN
Kegiatan / Lomba yang pernah diikuti :
1. .................................................................................................................................................................
2. .................................................................................................................................................................
3. .................................................................................................................................................................
4. .................................................................................................................................................................

Bekasi, Desember 2019

Photo 3 x 4 Peserta,
Berseragam pramuka

...........................................................
NTA :
Mengetahui,
Kepala Madrasah

.........................................................
NIP.
 FORM. 02
JAMBORE MI 2019

BIODATA PENDAMPING JAMBORE MI 2019

Nama Regu : .......................................................................................................................

Nomor / Nama Gudep : .......................................................................................................................
Pangkalan / Madrasah : .......................................................................................................................
Kwartir Ranting : .......................................................................................................................
Kwartir Cabang : .......................................................................................................................

I. UMUM
Nama : .......................................................................................................................
Tempat, Tgl. Lahir : .......................................................................................................................
NTA : .......................................................................................................................
Hobby : .......................................................................................................................
Cita-Cita : .......................................................................................................................
Telp/HP : .......................................................................................................................
Alamat : .......................................................................................................................

II. KEPRAMUKAAN
Kegiatan / Lomba yang pernah diikuti :
1. .................................................................................................................................................................
2. .................................................................................................................................................................
3. .................................................................................................................................................................
4. .................................................................................................................................................................

Bekasi, Desember 2019

Photo 3 x 4 Pendamping,
Berseragam pramuka

...........................................................
NTA :
Mengetahui,
Kepala Madrasah

.........................................................
NIP.
 FORM. 03.A-PUTRA
JAMBORE MI 2019

DAFTAR KOLEKTIF JAMBORE MI 2019

Yang bertanda tangan di bawah ini :

Nama : .......................................................................................................................
NTA : .......................................................................................................................
Tempat, Tgl. Lahir : .......................................................................................................................
Nomor / Nama Gudep : .......................................................................................................................
Pangkalan / Madrasah : .......................................................................................................................
Alamat : .......................................................................................................................
No. Tlp/HP : .......................................................................................................................

Mendaftarkan adik-adik kami yang namanya tercantum di bawah ini sebagai Peserta Jambore MI 2019
Perkemahan Penggalang Madrasah Ibtidaiyah se-Kabupaten Bekasi yang diselenggarakan oleh
Musyawarah Kelompok Kerja Madrasah ibtidaiyah Kabupaten Bekasi di Bumi Perkemahan Karang Kitri
Bojong Mangu Kabupaten Bekasi 17 – 19 Desember 2019
Nama Regu : ...............................................................................................

No Nama Kelas Keterangan

1
2
3
4
5
6
7
8
9
10

Demikian, atas perhatiannya kami sampaikan terima kasih.

……………………………………….. 2019

Kamabigus Pendamping

.................................................. .............................................
NTA : NTA :
 FORM. 03.B-PUTRI
JAMBORE MI 2019

DAFTAR KOLEKTIF JAMBORE MI 2019

Yang bertanda tangan di bawah ini :

Nama : .......................................................................................................................
NTA : .......................................................................................................................
Tempat, Tgl. Lahir : .......................................................................................................................
Nomor / Nama Gudep : .......................................................................................................................
Pangkalan / Madrasah : .......................................................................................................................
Alamat : .......................................................................................................................
No. Tlp/HP : .......................................................................................................................

Mendaftarkan adik-adik kami yang namanya tercantum di bawah ini sebagai Peserta Jambore MI 2019
Perkemahan Penggalang Madrasah Ibtidaiyah se-Kabupaten Bekasi yang diselenggarakan oleh
Musyawarah Kelompok Kerja Madrasah ibtidaiyah Kabupaten Bekasi di Bumi Perkemahan Karang Kitri
Bojong Mangu Kabupaten Bekasi 17 – 19 Desember 2019
Nama Regu : ...............................................................................................

No Nama Kelas Keterangan

1
2
3
4
5
6
7
8
9
10

Demikian, atas perhatiannya kami sampaikan terima kasih.

……………………………………….. 2019

Kamabigus Pendamping

.................................................. .............................................
NTA : NTA :
 FORM. 04
JAMBORE MI 2019

DAFTAR KOLEKTIF KKMI KEC. JAMBORE MI 2019

Yang bertanda tangan di bawah ini :

Nama : ......................................................................................................................
NTA : ......................................................................................................................
Tempat, Tgl. Lahir : ......................................................................................................................
Alamat : ......................................................................................................................
No. Tlp/HP : ......................................................................................................................

Menyampaikan Rekapitulasi Peserta Jambore MI 2019 Perkemahan Penggalang Madrasah Ibtidaiyah se-
Kabupaten Bekasi yang diselenggarakan oleh Musyawarah Kelompok Kerja Madrasah ibtidaiyah Kabupaten
Bekasi di Bumi Perkemahan Karang Kitri Bojong Mangu Kabupaten Bekasi 17 – 19 Desember 2019
Nama Kecamatan : ..............................................................................................

JML JML
No Nama Regu Kategori No/Nama Gudep
Peserta Pendamping
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
JUMLAH
Catatan : diisi sesuai kuota dan terpisah antara PUTRA dan PUTRI

Demikian, atas perhatiannya kami sampaikan terima kasih.

Bekasi, Desember 2019
Ketua KKMI Kec. ............................

......................................................
NTA
 SURAT IZIN ORANGTUA/WALI

Yang bertandatangan di bawah ini :

Nama : ..........................................................................................................
Usia : ..........................................................................................................
Pekerjaan : ..........................................................................................................
Alamat : ..........................................................................................................
..........................................................................................................

Dengan ini kami Memberikan Izin kepada :

Nama : ..........................................................................................................
Nomor Induk Siswa : ..........................................................................................................
Tempat/Tgl. Lahir : ..........................................................................................................
Jenis Kelamin : ..........................................................................................................
Kelas : ..........................................................................................................
Madrasah : ..........................................................................................................

Untuk mengikuti Kegiatan Jambore MI 2019 Perkemahan Penggalang Madrasah Ibtidaiyah

se-Kabupaten Bekasi mulai Tanggal 17 – 19 Desember 2019 di Bumi Perkemahan Karang Kitri
Kecamatan Bojong Mangu yang diselenggarakan oleh Kelompok Kerja Madrasah Ibtidaiyah
Kabupaten Bekasi.

Demikian, kami sampaikan kepada agar menjadi bahan pertimbangan bagi pihak madrasah/sekolah
dalam melaksanakan kegiatan.

Bekasi, ......... ................... 2019

Orangtua/Wali

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