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FORMULIR PENDAFTARAN KEMAH LITERASI MODERASI BERAGAMA

TAHUN 2023
NAMA LENGKAP : ............................................................................................................
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NAMA PANGGILAN : ............................................................................................................
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TEMPAT TANGGAL LAHIR : ............................................................................................................
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ALAMAT : ............................................................................................................
NO. TELP ORANGTUA : ............................................................................................................
PENYAKIT KHUSUS : ............................................................................................................
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MENYETUJUI ORANG TUA / WALI

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SURAT KETERANGAN IZIN ORANG TUA / WALI

YANG BERTANDA TANGAN DI BAWAH INI


NAMA ORANG TUA : ............................................................................................................
USIA : ............................................................................................................
ALAMAT : ............................................................................................................
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ORANG TUA / WALI DARI
NAMA ANAK : ............................................................................................................
USIA : ............................................................................................................
KELAS : ............................................................................................................
JENIS KELAMIN : ............................................................................................................
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ALAMAT : ............................................................................................................
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DENGAN INI MENYATAKAN :


TIDAK MERASA KEBERATAN JIKA ANAK KAMI SEBAGAIMANA TERSEBUT DI ATAS
MENGIKUTI KEMAH LITERASI MODERASI BERAGAMA DAN MENGINAP DI SEKOLAH SELAMA
KEGIATAN BERLANGSUNG (2 HARI 1 MALAM).

MENYETUJUI ORANG TUA / WALI

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