FORMULIR PENDAFTARAN PESERTA DIDIK BARU

RUANG HEBAT
Belajar BATUHI & Bimbingan Belajar

NPD :
A. IDENTITAS PESERTA DIDIK
1. Nama Lengkap :-----------------------------------------------------------------------------------
2. Tempat, Tanggal Lahir :------------------------------------------------------------------------------------
3. Jenis kelamin :------------------------------------------------------------------------------------
4. Agama :------------------------------------------------------------------------------------
5. Anak ke- :------------------------------------------------------------------------------------
6. Jumlah saudara :------------------------------------------------------------------------------------
7. Alamat Lengkap :------------------------------------------------------------------------------------
8. Asal Sekolah : -----------------------------------------------------------------------------------

B. IDENTITAS ORANG TUA / WALI

1. Nama Ayah :------------------------------------------------------------------------------------
2. Tempat, Tanggal Lahir : -----------------------------------------------------------------------------------
3. Agama :------------------------------------------------------------------------------------
4. Pendidikan :------------------------------------------------------------------------------------
5. Pekerjaan :------------------------------------------------------------------------------------
6. Alamat Kantor : -----------------------------------------------------------------------------------
7. No. Telephone :------------------------------------------------------------------------------------

1. Nama Ibu :------------------------------------------------------------------------------------

2. Tempat, Tanggal Lahir : -----------------------------------------------------------------------------------
3. Agama :------------------------------------------------------------------------------------
4. Pendidikan :------------------------------------------------------------------------------------
5. Pekerjaan :------------------------------------------------------------------------------------
6. Alamat Kantor : -----------------------------------------------------------------------------------
7. No. Telephone :------------------------------------------------------------------------------------

1. Nama Wali :------------------------------------------------------------------------------------

2. Tempat, Tanggal Lahir :------------------------------------------------------------------------------------
3. Agama :------------------------------------------------------------------------------------
4. Pendidikan :------------------------------------------------------------------------------------
5. Pekerjaan :------------------------------------------------------------------------------------
6. Alamat Kantor : -----------------------------------------------------------------------------------
7. No. Telephone :------------------------------------------------------------------------------------

C. ADMINISTRASI

1. Biaya Pendaftaran :
2. Tanggal Masuk : ------------------------------------------------------------------------------------------
3. Biaya SPP : ------------------------------------------------------------------------------------------
4. Status : ------------------------------------------------------------------------------------------

Cilacap, ………………………

Mengetahui
Orang Tua/Wali Guru Pembimbing

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