1. Nama lengkap :.................................................................................................................
2. Jenis kelamin :................................................................................................................. 3. Tempat dan tanggal lahir :................................................................................................................. 4. Umur :................................................................................................................. 5. Menguasai tarian (a) :................................................................................................................ (b) :................................................................................................................ (c) :................................................................................................................ (d) :................................................................................................................ 6. Alamat Rumah :................................................................................................................. :................................................................................................................. :................................................................................................................. 7. No telepon :................................................................................................................. 8. Status a. Pelajar b. Pekerja 9. Nama dan Alamat Sekolahan/ Pekerjaan :................................................................................................................. :................................................................................................................. 10. Nama orang tua a. Ayah :................................................................................................................. b. Ibu :................................................................................................................. 11. Alamat :................................................................................................................. :.................................................................................................................