INSIDE COURSE

Green Park Regency Blok S -4. Telp. 0821 4268 0500/0812 4998 6634

FORMULIR PENDAFTARAN
A. Data Siswa
1. Nama Lengkap : __________________________________________________
2. Nama Panggilan : __________________________________________________
3. Jenis Kelamin : __________________________________________________
4. Tempat, tanggal lahir : __________________________________________________
5. Agama : __________________________________________________
6. Anak ke : __________________________________________________
7. Sekolah : __________________________________________________
8. Kelas : __________________________________________________
9. Alamat : _______________________ No. _______ RT/RW: _________
Ds. ____________________ Kec. _______________________
Kab. ____________________
10. No. Telp. : __________________________________________________

B. Data Orang Tua/ Wali

1. Nama Ayah : __________________________________________________
Alamat : __________________________________________________
No. Telp. : __________________________________________________
2. Nama Ibu : __________________________________________________
Alamat : __________________________________________________
No. Telp. : __________________________________________________

C. Program (Beri Tanda Centang)

o Pra TK/PG
o TK Kelas : _________
o SD/MI Kelas : _________
o SMP/MTS Kelas : _________

D. Pilihan Hari Les

o Senin o Kamis
o Selasa o Jum’at
o Rabu

E. Pilihan Jam Belajar

o 18.00 – 19.30

Sidoarjo, ______________________________
Orang Tua/Wali Penerima Pendaftar
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