GERAKAN PRAMUKA

GUGUS DEPAN MTS NURUL HASANAH PENGAWU

Alamat : Jl. Padanjakaya No. 93 Telp. (0451) 462515 Palu SulTeng 94129
S

NOMOR
FORMULIR PENDAFTARAN ANGGOTA PENGGALANG

A. Identitas Diri
 Nama Lengkap : .....................................................................................................
 Nama Panggilan : .....................................................................................................
 TTL : .....................................................................................................
 Jenis Kelamin : .....................................................................................................
 Agama : .....................................................................................................
 Alamat Sekarang : .....................................................................................................
 No. HP : .....................................................................................................
 Bakat dan Hobby : .....................................................................................................
B. Identitas Keluarga
 Orang Tua
1. Nama Ayah : .....................................................................................................
Pekerjaan : .....................................................................................................
Alamat : .....................................................................................................
2. Nama Ibu : .....................................................................................................
Pekerjaan : .....................................................................................................
Alamat : .....................................................................................................
 Saudara Kandung : Jumlah Kakak : ....................... Jumlah Adik : ...........................
C. Riwayat Pendidikan
 SD/MI
Nama Sekolah : .....................................................................................................
Alamat : .....................................................................................................
Tahun Lulus : .....................................................................................................
D. Motivasi Masuk Pramuka
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Palu, ........................................2019
Mengetahui, Pendaftar
Orang tua/Wali

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 SURAT PERNYATAAN ORANG TUA/WALI

Saya yang bertanda tangan di bawah ini :

Nama :
Alamat :
No. Hp :
Pekerjaan :
Hubungan Keluarga :

Orang Tua/Wali Siswa Dari :

Nama :
Kelas :
TTL :
Alamat :

Dengan ini menyatakan, saya selaku orang tua/wali siswa yang namanya tercantum di atas
menyetujui siswa tersebut untuk mengikuti pelatihan pramuka setiap hari Jum’at pukul 16.00 Wita
sampai dengan selesai dan mengizinkan siswa tersebut untuk mengikuti setiap kegiatan kepramukaan
yang diadakan oleh Gudep MTs Nurul Hasanah Pengawu.

Demikian surat pernyataan dari kami selaku Orang tua/Wali, atas perhatian Bapak/Ibu Kami
ucapkan terima kasih.

Palu, ........................................2019
Orang tua/Wali

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