FORM PENDAFTARAN INTERNATIONAL AWARD SMKN 8 MALANG

APPLICATION FOR AN INDEPENDENT OPERATOR’S LICENCE

A: Information about the school/agency

1. Name of school / agency : SMK N 8 Malang
2. Postal Address : Jl. Teluk Pacitan Arjosari Malang 65126
3. Telephone : (0341) 479148 Fax: (0341) 479164 Email:
kesiswaan@smkn8mlg.sch.id
4 Name of head/person in change : …………………(Kosongi)……………………..
5. Age Range : 16 – 18
6. Is the school/agency :
Day or boarding? Day Private or public? public
Single Sex? Male/Female/Mixed Co- educational? Male / Female
7. Number of pupils on roll / young people in group aged 14 and
Above: 295
8. Nationalities, with approximate percentages : Indonesian
9. Language of instruction : Indonesian
10. Curriculum ( e.g. British, U.S, I.B, national ) / activities undertaken:
KTSP
11. School membership (e.g. ECIS,IBO): IAYP
Affiliation to (e.g.World Association of Girl Guides/Girl Scouts): ..(Kosongi)..

B. Information about the proposed Award Programme

12. Reason for applying for an Independent Operator’s licence (see the attached
conditions, paragraph 2) :
To train the students to know about themselves, such as characters responsibility, self confidence, ability to make plan and to manage themselves.
13. How did you hear about the Award Programme?
MKKS
14. Have you been an Award leader previously?
Yes I have
15. Names and positions of the Award leaders nominated to run the Programme:
a) Yoyok Prasetya, Vice headmaster of Student
b) Mafruzah, OSIS Leader
16. If they are teaching staff / group leaders, how much time will be allocated for
them to supervice the operation of the Award Programme?
Every month
17. Will funding be available to enable Award leaders to attend training courses,
workshops and conferences?
Yes, It Will
18. When are you planning to start the Programme? March 30 th 2009

19. With how many pupils/young people at each level (Bronze,Silver.Gold)?
………………………………(Kosongi)……………………………………………
20. How many adult will initially be involved in the Programme as instructors and
assessors? 15 Persons
School staff/Group leaders : 1 : Vice headmaster
Others : 14 : Guardian teachers
21. What activities are planned in each of the four Sections?
a) Services ………………………(Kosongi)……………………………….
………………………………………………………………….
b) Expenditions …………………………(Kosongi)…………………………….
………………………………………………………………….
c) Skills …………………………(Kosongi)…………………………….
………………………………………………………………….
d) Physical …………………………(Kosongi)…………………………….
Recreation

C : Declaration

I have read and accept the Conditions on which Independent Operators are Licenced.
I enclose the joining fee.

…………(Kosongi)…………………… …………(Kosongi)……………..
Signature of Head of school/Agency Date

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