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