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DATA SANTRIWATI ASRAMA “ RAHMANIAH 2021“

A. Santriwati
1. Nama lengkap : -----------------------------------------------------------------------------
2. Nama Panggilan : -----------------------------------------------------------------------------
3. Tempat Tanggal Lahir : -----------------------------------------------------------------------------
4. Jenis Kelamin : -----------------------------------------------------------------------------
5. Asal Sekolah / Madrasah : -----------------------------------------------------------------------------
6. Prestasi : -----------------------------------------------------------------------------
-----------------------------------------------------------------------------
7. NO HP / WA : -----------------------------------------------------------------------------
8. Alamat Rumah : -----------------------------------------------------------------------------
9. Uang jajan/hari : -----------------------------------------------------------------------------
10. Penyakit yang diderita : -----------------------------------------------------------------------------

B. Orang Tua / Wali


Ayah
a. Nama : -----------------------------------------------------------------------------
b. NO HP / WA : -----------------------------------------------------------------------------
c. Pekerjaan : -----------------------------------------------------------------------------
d. Alamat tinggal : -----------------------------------------------------------------------------
Ibu
a. Nama : -----------------------------------------------------------------------------
b. NO HP / WA : -----------------------------------------------------------------------------
c. Pekerjaan : -----------------------------------------------------------------------------
d. Alamat tinggal : -----------------------------------------------------------------------------
Wali
a. Nama : -----------------------------------------------------------------------------
b. NO HP / WA : -----------------------------------------------------------------------------
c. Pekerjaan : -----------------------------------------------------------------------------
d. Alamat tinggal : -----------------------------------------------------------------------------
Gorontalo, 2021

Nama Peserta Didik

3x4

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