SMAN 10 Bekas! New Student Registration Form ‘STUDENT INFORMATION: Name Sage Date of birth YAS. Qt 200 0 Male o Female Religion : HeightWeight We LAL Has the student ever been registered at other schoo! 0 Yes WY No Within Area? It Yes, provide the name of the school within ‘Area most recently attended: MEDICAL INFORMATION: Blood type: MEDICAL CONDITIONS: If you have significant health factors of which the school should be aware, please describe the condition(s) below. oO Yes & No HOME ADDRESS: Proof Address Required Village Se fs Subdistrict City/Town a.Berat PostalCode V9! Phone Number: PARENT AND/OR LEGAL GAURDIAN INFORMATION ONLY FirstName S¥.S.29.8. Last Name Relationship & Mother Father Step Parent G Foster Parent Dipindai dengan CamScannerLegal Guardian Adress - Haber fea byrnmw 8.109 Subdistrict _{M. (m8 City/Town {are postal Code Province Phone Number: 25 EMERGENCY CONTACT INFORMATION If parentguardian not available, contact this person. Last Name FirstName ar 0 Male & Female Relationship to student: ADDITIONAL STUDENT INFORMATION: (if required by the schoo!) | certify that the information given on this form is correct: Student Signature Parent/Guardian Signature: Poh Syerita Amanda Name: Dipindai dengan CamScanner