FORM.

A1

FORMULIR PENDAFTARAN

LOMBA TINGKAT REGU PENGGALANG (LT) II

GERAKAN PRAMUKA : KWARTIR RANTING

CIBEBER PANGKALAN : ................................................................................

GUDEP : ...............................................................................

REGU : ...............................................................................

ALAMAT : ...............................................................................................................................................................

NO NTA NAMA KETERANGAN

1 PINRU

2 WAPINRU

3 ANGGOTA

4 ANGGOTA

5 ANGGOTA

6 ANGGOTA

7 ANGGOTA

8 ANGGOTA

Cibeber, Agustus 2022

Bindamping,

……………………………………..
NTA.
FORM. A2

BIODATA PESERTA

LOMBA TINGKAT REGU PENGGALANG (LT) II

GERAKAN PRAMUKA : KWARTIR RANTING CIBEBER

PANGKALAN : ................................................................................

GUDEP : ...............................................................................

REGU : ...............................................................................

ALAMAT : ...............................................................................................................................................................

PEMIMPIN REGU
Nama Lengkap : .....................................................................
TTL : .........................., .........................................

Foto Berwarna Kelas / NIS : .....................................................................

Nama Orang Tua (Ayah / ibu) : .....................................................................
(3x4)
Nomor Telepon Orang Tua : .....................................................................
Alamat Rumah : .....................................................................

WAKIL PEMIMPIN REGU

Nama Lengkap : .....................................................................
TTL : .........................., .........................................

Foto Berwarna Kelas / NIS : .....................................................................

Nama Orang Tua (Ayah / ibu) : .....................................................................
(3x4)
Nomor Telepon Orang Tua : .....................................................................
Alamat Rumah : .....................................................................

ANGGOTA
Nama Lengkap : .....................................................................
TTL : .........................., .........................................

Foto Berwarna Kelas / NIS : .....................................................................

Nama Orang Tua (Ayah / ibu) : .....................................................................
(3x4)
Nomor Telepon Orang Tua : .....................................................................
Alamat Rumah : .....................................................................
 ANGGOTA
Nama Lengkap : .....................................................................
TTL : .........................., .........................................

Foto Berwarna Kelas / NIS : .....................................................................

Nama Orang Tua (Ayah / ibu) : .....................................................................
(3x4)
Nomor Telepon Orang Tua : .....................................................................
Alamat Rumah : .....................................................................

ANGGOTA
Nama Lengkap : .....................................................................
TTL : .........................., .........................................

Foto Berwarna Kelas / NIS : .....................................................................

Nama Orang Tua (Ayah / ibu) : .....................................................................
(3x4)
Nomor Telepon Orang Tua : .....................................................................
Alamat Rumah : .....................................................................

ANGGOTA
Nama Lengkap : .....................................................................
TTL : .........................., .........................................

Foto Berwarna Kelas / NIS : .....................................................................

Nama Orang Tua (Ayah / ibu) : .....................................................................
(3x4)
Nomor Telepon Orang Tua : .....................................................................
Alamat Rumah : .....................................................................

ANGGOTA
Nama Lengkap : .....................................................................
TTL : .........................., .........................................

Foto Berwarna Kelas / NIS : .....................................................................

Nama Orang Tua (Ayah / ibu) : .....................................................................
(3x4)
Nomor Telepon Orang Tua : .....................................................................
Alamat Rumah : .....................................................................

ANGGOTA
Nama Lengkap : .....................................................................
TTL : .........................., .........................................

Foto Berwarna Kelas / NIS : .....................................................................

Nama Orang Tua (Ayah / ibu) : .....................................................................
(3x4)
Nomor Telepon Orang Tua : .....................................................................
Alamat Rumah : .....................................................................
FORM. B

BIODATA PEMBINA PENDAMPING

LOMBA TINGKAT REGU PENGGALANG (LT) II

GERAKAN PRAMUKA : KWARTIR RANTING CIBEBER

PANGKALAN : ................................................................................

GUDEP : ...............................................................................

REGU : ...............................................................................

ALAMAT : ...............................................................................................................................................................

PEMBINA PENDAMPING
Nama Lengkap : .........................................................................................................
NTA : .........................................................................................................

Foto Berwarna TTL : ........................................, ...............................................................

No Telepon : .........................................................................................................
(3x4)
Alamat Email : .........................................................................................................
Pekerjaan : .........................................................................................................
Alamat : .........................................................................................................
.........................................................................................................

Cibeber, Agustus 2022

Mengetahui, Pembina Gudep

……………………………………………………………
NTA.
 SURAT IZIN ORANG TUA/WALI

Saya yang bertandatangan dibawah ini:

Nama Orang Tua : Yuli Sugianto

Jenis kelamin : Laki-laki
Alamat Orang Tua : Jl. Raya Bayah-Cikotok Km. 01 Ds. Cikotok Kec. Cibeber
Kab. Lebak 42394
Telp/Hp Orang Tua : 085892751847
Hubungan Keluarga : Anak kandung

Orang Tua/Wali Siswa Dari

Nama : Adyla Julsaecar Sugianto
Tempat Tanggal Lahir : Lebak, 20 Juli 2011
Sekolah : SDN 2 Cikotok

Sesuai dengan ketentuan persyaratan Lomba Tingkat Regu Penggalang (LT) II Kwartir Ranting
Cibeber Tahun 2022, dengan ini saya menyatakan, selaku orang tua/wali siswa/siswi yang
namanya tercantum di atas menyetujui/mengizinkan untuk mengikuti Lomba Tingkat Regu
Penggalang (LT) II Kwartir Ranting Cibeber Tahun 2022.

Demikian surat persetujuan/izin ini untuk dapat dipergunakan sebagaimana mestinya.

Cibeber, Agustus 2022

Orang Tua/Wali,