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FORMULIR PENDAFTARAN ANGGOTA BARU

GUDEP 01.009-01.010 PANGKALAN SMKN 1 MUARA TEWEH


TAHUN PELAJARAN 2023/2024

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


2. Jenis Kelamin :.................................................................................................
3. Tempat & Tanggal Lahir :.................................................................................................
4. Agama :.................................................................................................
5. Alamat :.................................................................................................
6. Golongan Darah :a. A
b. B
c. O
d. AB
e. Tidak Tau
7. Kelas & Jurusan :.................................................................................................
8. Nama Orang Tua/Wali :.................................................................................................
9. Pekerjaan Orang Tua/Wali :.................................................................................................
10. Hobi :.................................................................................................
11. Bakat :.................................................................................................
12. Riwayat Kesehatan :.................................................................................................
13. Nomor Telepon (Whatsapp) :.................................................................................................
14. Pengalaman Kepramukaan :a. Siaga
b. penggalang
c. Belum Pernah

Muara Teweh,.....................................
Peserta Didik
Pas Foto
3x4

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