Buku

Ke-1A

BUKU REGISTRASI PESERTA DIDIK

GERAKAN PRAMUKA
GUGUS DEPAN 09.06.03.057 – 09.06.03.058
PANGKALAN SMPN 1 RAJAPOLAH
 FORM REGISTRASI CALON ANGGOTA PRAMUKA
GUGUS DEPAN 09.06.03.057 – 058 PANGKALAN SMPN 1 RAJAPOLAH

1. Nama Lengkap : ..................................................................... ( Pa / Pi )

2. Tempat/Tgl. Lahir : .......................................................................................
3. Agama : .......................................................................................
4. Nama Orang Tua / Wali : ....................................................................................... Pas Photo
5. Pekerjaan Orang tua/wali 2x3
 Ayah : .......................................................................................
 Ibu : .......................................................................................
6. Alamat Rumah
 Orang tua : Kp. ......................................................................... RT ......... RW ..........
Desa ...........................................................................................................
Kecamatan ...............................................................................................
Kabupaten ................................................................................................
Telp./HP ....................................................................................................
 Peserta didik : Kp. ......................................................................... RT ......... RW ..........
Desa ...........................................................................................................
Kecamatan ...............................................................................................
Kabupaten ................................................................................................
Telp./HP ....................................................................................................
7. Anak ke- : .......... Jml saudara : Pa .......... Pi ..........
8. Golongan Darah : .....................................................................................................................
9. Sekolah : SMP Negeri 1 Rajapolah
10. Bakat / Hobi : 1. .................................................................................................................
2. .................................................................................................................
3. .................................................................................................................
11. Hal-hal yang perlu diperhatikan (kesehatan, kebiasaan, bahasa yg dikuasai dll) :
...................................................................................................................................................................................
...................................................................................................................................................................................
...................................................................................................................................................................................
12. Pengalaman dalam Kepramukaan : Thn .................... sebagai .......................................................
Thn .................... sebagai .......................................................
Thn .................... sebagai .......................................................
13. Lain-lain :
...................................................................................................................................................................................
...................................................................................................................................................................................

Mengetahui Tasikmalaya, ........................................

Orang Tua/Wali, Calon Anggota,

............................................................ ............................................................
Mengetahui :
Ketua Gudep, Pembina,

Didi Sadri Usman, S.Pd. ............................................................

NTA. 09.06.03.057.0003 NTA. 09.06.03.057.00...
 Buku
Ke-1B

BUKU REGISTRASI
PEMBINA & ANGGOTA MABI
GERAKAN PRAMUKA
GUGUS DEPAN 09.06.03.057 – 09.06.03.058
PANGKALAN SMPN 1 RAJAPOLAH
 FORM REGISTRASI PEMBINA & ANGGOTA MABI
GUGUS DEPAN 09.06.03.057 – 058 PANGKALAN SMPN 1 RAJAPOLAH

1. Nama Lengkap : ..................................................................... ( Pa / Pi )

2. Tempat/Tgl. Lahir : .......................................................................................
3. NTA : .......................................................................................
Pas Photo
4. Alamat Rumah : Kp. ........................................... RT ......... RW ..........
2x3
Desa .............................................................................
Kecamatan .................................................................
Kabupaten ..................................................................
Telp./HP ......................................................................
5. Jabatan dalam :
 Masyarakat/Pemerintah : .....................................................................................................................
 Mabi / Gudep : .....................................................................................................................
6. Agama : Islam
7. Status Perkawinan : .....................................................................................................................
8. Golongan Darah : .....................................................................................................................
9. No, Tgl Sertifikat, Ijazah : SMP Negeri 1 Rajapolah
 KO / OPK : Nomor ......................................................................................................
Tanggal Sertifikat ....................................................................................
Tempat Kegiatan ....................................................................................
 KMD : Nomor ......................................................................................................
Tanggal Sertifikat ....................................................................................
Tempat Kegiatan ....................................................................................
 KML : Nomor ......................................................................................................
Tanggal Sertifikat ....................................................................................
Tempat Kegiatan ....................................................................................
 KPD : Nomor ......................................................................................................
Tanggal Sertifikat ....................................................................................
Tempat Kegiatan ....................................................................................
 KPL : Nomor ......................................................................................................
Tanggal Sertifikat ....................................................................................
Tempat Kegiatan ....................................................................................
10. Pengalaman Pendidikan : SD ............................................................. Tahun Lulus .........................
SMP ........................................................... Tahun Lulus .........................
SMA .......................................................... Tahun Lulus .........................
S.1 ............................................................ Tahun Lulus .........................
S.2 ............................................................ Tahun Lulus .........................
S.3 .............................................................. Tahun Lulus .........................
13. Lain-lain :
...................................................................................................................................................................................
...................................................................................................................................................................................

Rajapolah, ...........................................
Mengetahui
Mabigus, Ketua Gudep,

Drs. H. Ade Dasmana, M.SI Didi Sadri Usman, S.Pd.

NTA. 09.06.03.057.0001 NTA. 09.06.03.057.0003