Tahun Ajaran : ......................................................
Semester :
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Kegiatan ekstrakulikuler
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NO
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Kegiatan
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Nilai
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Baik
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Cukup
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Kurang
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1.
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Qiro’ah
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2.
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Muhafadzoh
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3.
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Sorogan
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4.
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5.
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6.
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7.
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Catatan
Untuk Orang tua : ...............................................................................
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Di Berikan :..............................................
Tanggal :
..............................................
Mengetahui,
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Wali Kelas
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Wali Santri
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Pengasuh
Ky. Muhdzir Saifulloh
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