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PENDATAAN YATIM PIATU DAMPAK COVID-19
Formulir ini digunakan untuk pendataan warga Yatim-Piatu dengan usia Maksimal 17 Tahun karena dampak COVID-19 di Kapanewon Banguntapan
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Nama Lengkap
*
Your answer
Tanggal Lahir
*
MM
/
DD
/
YYYY
Jenis Kelamin
*
Laki-Laki
Perempuan
Other:
Disabilitas
*
Ya
Tidak
Alamat
Tulis sesuai Domisil Penduduk
RT
*
Your answer
Padukuhan
*
Your answer
Kalurahan
*
Your answer
Nomor Kontak(HP)
Your answer
Status Yatim/Piatu
*
Yatim
Piatu
Yatim/Piatu
Nama Orang Tua
Ayah
Your answer
Ibu
Your answer
Penerima Bantuan Sosial pemerintah
BPJS
PKH
BPNT
Tidak Mendapat Bantuan Sosial
Other:
Status Tinggal
Bersama Keluarga
Panti Asuhan
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Keterangan (Catatan Tambahan)
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