LEO LEADERSHIP CAMP 2017
NAMA LENGKAP/FULL NAME
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JENIS KELAMIN/SEX
ALAMAT/ADDRESS
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KOTA/CITY
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TELEPON/TELEPHONE NUMBER
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HP/PHONE NUMBER
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EMAIL
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INSTAGRAM
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NAMA CLUB/CLUB NAME
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ASAL DISTRIK/DISTRICT
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JABATAN DI CLUB/POSITION
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JABATAN DI DISTRIK/MULTIDISTRIK
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DIETARY?
CONTACT PERSON DALAM KEADAAN DARURAT /CONTACT PERSON ON EMERGENCY (NAME, NO.HP, RELATION)
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KETERANGAN KESEHATAN/MEDICAL STATUS
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BIAYA PENDAFTARAN/REGISTRATION FEE
TANGGAL TRANSFER/TRANSFER DATE
MM
/
DD
/
YYYY
ATAS NAMA/REFERRAL
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UKURAN KAOS/T-SHIRT SIZE
JENIS TRANSPORT KEDATANGAN/ARRIVAL TRANSPORTATION
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TANGGAL KEDATANGAN/ARRIVAL DATE
MM
/
DD
/
YYYY
WAKTU KEDATANGAN/ARRIVAL TIME
Time
:
JENIS TRANSPORT KEPULANGAN/DEPARTURE TRANSPORTATION
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TANGGAL KEPULANGAN/DEPARTURE DATE
MM
/
DD
/
YYYY
WAKTU KEPULANGAN/DEPARTURE TIME
Time
:
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