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Formulir Pendaftaran
Penerimaan Santri Baru Al-Qur'an Center Ummu Habibah 2022/2023
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Nama Lengkap
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IDENTITAS CALON SANTRI
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Nama Panggilan
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Tempat Lahir
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Tanggal Lahir
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Daftar Sebagai
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Santri baru (kelas 1)
Santri mutasi (pindahan)
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Daftar ke kelas
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Kelas 1
Kelas 2
Kelas 3
Kelas 4
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Anak ke .....
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1
2
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Dari ..... bersaudara
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1
2
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RIWAYAT KESEHATAN
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Tinggi Badan
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dalam cm
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Berat Badan
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dalam kg
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Golongan Darah
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A
B
AB
O
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Mata
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Normal
Berkacamata
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Riwayat Penyakit
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tuliskan diagnosa, tahun, dan keterangan (di-opname atau tidak)
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Riwayat Imunisasi
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DPT, Polio, Hepatitis, BCG, meningitis, Campak, MMR, HIB, lain lain
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Kebiasaan Baik
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Kebiasaan Buruk
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KEPRIBADIAN
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Hobi
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Karakter yang Menonjol
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Potensi dan Bakat
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Prestasi yang Pernah Diraih
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Kebiasaan di Rumah
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