Branch Muara KarangSenopati
**please contact us for other branches

A: PERSONAL DETAILS
Student Family Name

Student Given Name

Sex
MaleFemale

Address

Address 2


Postal Code

Nationality

Religion

First language spoken

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B: FAMILY BACKGROUND

Father's Name

Identity No/KTP No

Nationality

Country of Birth

Occupation

Religion

Contact Number

Mother's Name

Identity No/KTP No

Nationality

Country of Birth

Occupation

Religion

Contact Number

Your Correspondence E-mail

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C: HEALTH

Is there any medical condition of which teachers should be aware? YesNo
If yes, give details

Is student on regular medication? If yes, give details.

Name of Family Doctor

Contact Number

Contact Person in case of emergency (Other than parents)
Name

Relationship

Contact Number

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School rules and regulations Read Here