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YAYASAN BAITURRAHMAN
LEMBAGA PENDIDIKAN ISLAM MIFTAHUL ULUM
SEKOLAH DASAR ISLAM MIFTAHUL ULUM
Alamat : Jln. Teuku Umar No. 68/ Masjid Baiturrahman Bendosari – Kras – Kediri
Telp : (0354)412612 email : [email protected]
Facebook : Miftahul Ulum Kode Pos : 64172
KEMENKUMHAM : Nomor AHU – 0004492. AN.01.04 Tahun 2016
FORMULIR PENDAFTARAN
Nomor Pendaftaran
(diisi panitia)
I. IDENTITAS ANAK DIDIK
1. a. Nama lengkap
b. Nama Panggilan
:
.......................................................................................
:
.......................................................................................
2. Jenis Kelamin
: ......................................................................................
3. Tempat tanggal Lahir
:
.......................................................................................
4. Alamat Rumah
:
.......................................................................................
.......................................................................................
5. Anak Ke
:
Ke - ...................dari .................saudara
6. Kelas
:
.......................................................................................
II. IDENTITAS ORANG TUA / WALI
1. a. Nama Ayah
:
.......................................................................................
b. Tempat dan Tgl Lahir
:
.......................................................................................
c. Pendidikan terakhir
:
.......................................................................................
d. Pekerjaan
:
.......................................................................................
e. Hubungan dengan anak
:
.......................................................................................
g. Alamat
:
.......................................................................................
h. Telp. Rumah/ HP
:
.......................................................................................
2. a. Nama Ibu
: ......................................................................................
b. Tempat dan Tgl. Lahir
:
.......................................................................................
c. Pendidikan terakhir
:
.......................................................................................
d. Pekerjaan
: ......................................................................................
e. Hubungan dengan anak
:
.......................................................................................
g. Alamat
:
.......................................................................................
h. Telp. Rumah/ HP
:
.......................................................................................
........................................2021
ORANG TUA/WALI
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