PEMERINTAH KABUPATEN TANJUNG JABUNG TIMURPENDIDIKAN ANAK USIA DINI ( PAUD )

KELOMPOK BERMAIN AL – MADANI KELURAHAN PARIT CULUM IKECAMATAN MUARA SABAK BARAT

FORMULIR PENDAFTARAN ANAK Nomor :.........................................

A. Identitas AnakNama Lengkap :.................................................................................................................................................Nama Panggilan :.................................................................................................................................................Tempat Tanggal Lahir:.................................................................................................................................................Jenis Kelamin :.................................................................................................................................................Agama :.................................................................................................................................................Anak Ke :.................................................................................................................................................Jumlah Saudara :.................................................................................................................................................Alamat Rumah :.................................................................................................................................................

B. Kondisi Tumbuh Kembang AnakBerat Badan :.................................................................................................................................................Tinggi Badan :.................................................................................................................................................Lingkar Kepala :.................................................................................................................................................Penyakit / Gangguan:.................................................................................................................................................

Yang sering diderita :................................................................................................................................................. Yang pernah diderita:.................................................................................................................................................

C. Identitas Orang Tua / WaliNama Ayah :..................................................................................................................................................Umur Ayah :..................................................................................................................................................Pendidikan Ayah :..................................................................................................................................................Pekerjaan Ayah :..................................................................................................................................................Nama Ibu :..................................................................................................................................................Umur Ibu :..................................................................................................................................................Pendidikan Ibu :..................................................................................................................................................Pekerjaan Ibu :..................................................................................................................................................Nama Wali :.................................................................................................................................................Klasifikasi Kesejahteraan : Kurang mampu / Sedang / MampuNomor HP Ibu :..................................................................................................................................................Diterima di PAUD,Tanggal :.........................................................................................................................................

Muara Sabak Barat, ...............................2015 Orang Tua / Wali Calon Siswa

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Persyaratan :

1. Fotocopy Akte Kelahiran 2 lembar2. Foto berwarna 3 x 4 = 4 lembar3. Membayar uang pendaftaran