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PENDAFTARAN VAKSINASI DIFABEL
Vaksinasi untuk difabel Kab. Bantul
Waktu pelaksanaan 28-29 Agustus 2021 (sesuai jadwal yang ditentukan)
Tempat pelaksanaan di BRTPD Pundong
( PENDAFTARAN DITUTUP 26 AGUSTUS 2021 JAM 14.00 WIB )
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NAMA
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NIK
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di isi NIK yang sesuai
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UMUR
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ALAMAT DOMISILI
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ALAMAT SESUAI KTP
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KALURAHAN
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Choose
Banguntapan
Baturetno
Potorono
Jambidan
Wirokerten
Tamanan
Singosaren
Jagalan
Kapanewon/Kecamatan
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Banguntapan
Ragam Disabilitas
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Disabiltas Fisik
Disabilitas Sensorik
Disabilitas Mental
Disabilitas Intelektual
*Pendamping disabilitas
No Telp
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di isi no whatsapp yang bisa di hubungi
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Keterangan
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daksa
eks sakit ( misal : stroke menahun )
netra
autis
rungu
wicara
rungu wicara
gangguan jiwa
downsyndrome
grahita
lainya
Mobilitas ke lokasi
sendiri/dengan keluarga
memerlukan penjemputan
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