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<meta name="viewport" content="width=device-width, initial-scale=1">
<link rel="stylesheet" type="text/css" href="//assets.emailmeform.com/styles/dynamic.php?t=post&enable_responsive_ui=1&RU1GLTAyLTE4LTEwMzcy" />
<link rel="stylesheet" type="text/css" href="http://app.emailmeform.com/builder/theme_css/f2af8F0MAKf" />
<style>
#emf-container, #emf-container-outer #emf-form-shadows{box-sizing: border-box;-webkit-box-sizing: border-box;-moz-box-sizing: border-box;width:640px}
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</style>
<div id="emf-container-outer">
<div id="emf-container" >
<div id="emf-logo"><a>EmailMeForm</a></div>
<div class="emf-error-message" style='display:none'></div>
<form id="emf-form" target="_self" class="leftLabel" enctype="multipart/form-data" method="post" action="http://www.emailmeform.com/builder/form/f2af8F0MAKf"><div id="emf-form-instruction" class="emf-head-widget">
<div id="emf-form-title" class="emf-bold">Registrasi Buku Induk</div><div id="emf-form-description"></div>
</div>
<ul>
<li id="emf-li-0" class="emf-li-field emf-field-number data_container ">
<label class="emf-label-desc" for="element_0">Nomor Induk Siswa :</label>
<div class="emf-div-field"><input id="element_0" name="element_0"
class="validate[optional,custom[extNumber]]"
value="" size="30" type="text" /></div>
<div class="emf-clear"></div>
</li><li id="emf-li-1" class="emf-li-field emf-field-number data_container ">
<label class="emf-label-desc" for="element_1">Nomor Tanda Anggota :</label>
<div class="emf-div-field"><input id="element_1" name="element_1"
class="validate[optional,custom[extNumber]]"
value="" size="30" type="text" /></div>
<div class="emf-clear"></div>
</li><li id="emf-li-2" class="emf-li-field emf-field-file data_container ">
<label class="emf-label-desc" for="element_2">Foto</label>
<div class="emf-div-field"><input id="element_2" name="element_2" onchange="EMF_jQuery(this).blur()"
class="validate[optional,funcCall[check_file_error[null,2M]]]" type="file" /><div class="emf-div-instruction">Foto 3x4 menggunkan seragam sekolah</div></div>
<div class="emf-clear"></div>
</li><li id="emf-li-3" class="emf-li-field emf-field-new_name data_container ">
<label class="emf-label-desc" for="element_3">Nama :</label>
<div class="emf-div-field"><span style="width:60px">
<input class="validate[optional]" style="width:100%" value=""
id="element_5" name="element_5" type="text" />
<label for="element_5" class="emf-bottom-label emf-text-center">First</label>
</span><span style="width:100px">
<input class="validate[optional]" style="width:100%" value=""
id="element_6" name="element_6" type="text" />
<label for="element_6" class="emf-bottom-label emf-text-center">Last</label>
</span><div class="emf-div-instruction">Nama Lengkap!</div></div>
<div class="emf-clear"></div>
</li><li id="emf-li-10" class="emf-li-field emf-field-new_address data_container ">
<label class="emf-label-desc" for="element_10">Alamat :</label>
<div class="emf-div-field">
<div style="width:99%;">
<span class="emf-full emf-field-new_address-addr1">
<input type="text" value="" id="element_11" name="element_11" class="emf-full validate[optional]" />
<label for="element_11" class="emf-bottom-label">Street Address</label>
</span>
<span class="emf-left emf-half emf-field-new_address-city">
<input type="text" value="" id="element_13" name="element_13" class="emf-full validate[optional]" />
<label for="element_13" class="emf-bottom-label">City</label>
</span>
<span class="emf-right emf-half emf-field-new_address-state">
<input type="text" value="" id="element_14" name="element_14" class="emf-full validate[optional]" />
<label for="element_14" class="emf-bottom-label">State / Province / Region</label>
</span>
<span class="emf-left emf-half emf-field-new_address-zipcode">
<input type="text" value="" id="element_15" name="element_15" class="emf-full validate[optional]" />
<label for="element_15" class="emf-bottom-label">Postal / Zip Code</label>
</span>
<span class="emf-right emf-half emf-field-new_address-country">
<select id="element_16" name="element_16" class="emf-address validate[optional]">
<option value=''> </option><optgroup label="North America"><option value="Antigua and Barbuda" >Antigua and Barbuda</option><option value="Aruba" >Aruba</option><option value="Bahamas" >Bahamas</option><option value="Barbados" >Barbados</option><option value="Belize" >Belize</option><option value="Canada" >Canada</option><option value="Cayman Islands" >Cayman Islands</option><option value="Cook Islands" >Cook Islands</option><option value="Costa Rica" >Costa Rica</option><option value="Cuba" >Cuba</option><option value="Dominica" >Dominica</option><option value="Dominican Republic" >Dominican Republic</option><option value="El Salvador" >El Salvador</option><option value="Grenada" >Grenada</option><option value="Guatemala" >Guatemala</option><option value="Haiti" >Haiti</option><option value="Honduras" >Honduras</option><option value="Jamaica" >Jamaica</option><option value="Mexico" >Mexico</option><option value="Netherlands Antilles" >Netherlands Antilles</option><option value="Nicaragua" >Nicaragua</option><option value="Panama " >Panama </option><option value="Puerto Rico " >Puerto Rico </option><option value="Saint Kitts and Nevis" >Saint Kitts and Nevis</option><option value="Saint Lucia" >Saint Lucia</option><option value="Saint Vincent and the Grenadines" >Saint Vincent and the Grenadines</option><option value="Trinidad and Tobago" >Trinidad and Tobago</option><option value="United States" >United States</option></optgroup><optgroup label="South America"><option value="Argentina" >Argentina</option><option value="Bolivia" >Bolivia</option><option value="Brazil" >Brazil</option><option value="Chile" >Chile</option><option value="Colombia" >Colombia</option><option value="Ecuador" >Ecuador</option><option value="Guyana" >Guyana</option><option value="Paraguay" >Paraguay</option><option value="Peru" >Peru</option><option value="Suriname" >Suriname</option><option value="Uruguay" >Uruguay</option><option value="Venezuela" >Venezuela</option></optgroup><optgroup label="Europe"><option value="Albania" >Albania</option><option value="Andorra" >Andorra</option><option value="Armenia" >Armenia</option><option value="Austria" >Austria</option><option value="Azerbaijan" >Azerbaijan</option><option value="Belarus" >Belarus</option><option value="Belgium" >Belgium</option><option value="Bosnia and Herzegovina" >Bosnia and Herzegovina</option><option value="Bulgaria" >Bulgaria</option><option value="Croatia" >Croatia</option><option value="Cyprus" >Cyprus</option><option value="Czech Republic" >Czech Republic</option><option value="Denmark" >Denmark</option><option value="Estonia" >Estonia</option><option value="Faroe Islands" >Faroe Islands</option><option value="Finland" >Finland</option><option value="France" >France</option><option value="Georgia" >Georgia</option><option value="Germany" >Germany</option><option value="Greece" >Greece</option><option value="Hungary" >Hungary</option><option value="Iceland" >Iceland</option><option value="Ireland" >Ireland</option><option value="Italy" >Italy</option><option value="Kosovo" >Kosovo</option><option value="Latvia" >Latvia</option><option value="Liechtenstein" >Liechtenstein</option><option value="Lithuania" >Lithuania</option><option value="Luxembourg" >Luxembourg</option><option value="Macedonia" >Macedonia</option><option value="Malta" >Malta</option><option value="Moldova" >Moldova</option><option value="Monaco" >Monaco</option><option value="Montenegro" >Montenegro</option><option value="Netherlands" >Netherlands</option><option value="Norway" >Norway</option><option value="Poland" >Poland</option><option value="Portugal" >Portugal</option><option value="Romania" >Romania</option><option value="San Marino" >San Marino</option><option value="Serbia" >Serbia</option><option value="Slovakia" >Slovakia</option><option value="Slovenia" >Slovenia</option><option value="Spain" >Spain</option><option value="Sweden" >Sweden</option><option value="Switzerland" >Switzerland</option><option value="Ukraine" >Ukraine</option><option value="United Kingdom" >United Kingdom</option><option value="Vatican City" >Vatican City</option></optgroup><optgroup label="Asia"><option value="Afghanistan" >Afghanistan</option><option value="Bahrain" >Bahrain</option><option value="Bangladesh" >Bangladesh</option><option value="Bhutan" >Bhutan</option><option value="Brunei Darussalam" >Brunei Darussalam</option><option value="Myanmar" >Myanmar</option><option value="Cambodia" >Cambodia</option><option value="China" >China</option><option value="East Timor" >East Timor</option><option value="Hong Kong" >Hong Kong</option><option value="India" >India</option><option value="Indonesia" >Indonesia</option><option value="Iran" >Iran</option><option value="Iraq" >Iraq</option><option value="Israel" >Israel</option><option value="Japan" >Japan</option><option value="Jordan" >Jordan</option><option value="Kazakhstan" >Kazakhstan</option><option value="North Korea" >North Korea</option><option value="South Korea" >South Korea</option><option value="Kuwait" >Kuwait</option><option value="Kyrgyzstan" >Kyrgyzstan</option><option value="Laos" >Laos</option><option value="Lebanon" >Lebanon</option><option value="Malaysia" >Malaysia</option><option value="Maldives" >Maldives</option><option value="Mongolia" >Mongolia</option><option value="Nepal" >Nepal</option><option value="Oman" >Oman</option><option value="Pakistan" >Pakistan</option><option value="Palestine" >Palestine</option><option value="Philippines" >Philippines</option><option value="Qatar" >Qatar</option><option value="Russia" >Russia</option><option value="Saudi Arabia" >Saudi Arabia</option><option value="Singapore" >Singapore</option><option value="Sri Lanka" >Sri Lanka</option><option value="Syria" >Syria</option><option value="Taiwan" >Taiwan</option><option value="Tajikistan" >Tajikistan</option><option value="Thailand" >Thailand</option><option value="Turkey" >Turkey</option><option value="Turkmenistan" >Turkmenistan</option><option value="United Arab Emirates" >United Arab Emirates</option><option value="Uzbekistan" >Uzbekistan</option><option value="Vietnam" >Vietnam</option><option value="Yemen" >Yemen</option></optgroup><optgroup label="Oceania"><option value="Australia" >Australia</option><option value="Fiji" >Fiji</option><option value="Kiribati" >Kiribati</option><option value="Marshall Islands" >Marshall Islands</option><option value="Micronesia" >Micronesia</option><option value="Nauru" >Nauru</option><option value="New Zealand" >New Zealand</option><option value="Palau" >Palau</option><option value="Papua New Guinea" >Papua New Guinea</option><option value="Samoa" >Samoa</option><option value="Solomon Islands" >Solomon Islands</option><option value="Tonga" >Tonga</option><option value="Tuvalu" >Tuvalu</option><option value="Vanuatu" >Vanuatu</option></optgroup><optgroup label="Africa"><option value="Algeria" >Algeria</option><option value="Angola" >Angola</option><option value="Benin" >Benin</option><option value="Botswana" >Botswana</option><option value="Burkina Faso" >Burkina Faso</option><option value="Burundi" >Burundi</option><option value="Cameroon" >Cameroon</option><option value="Cape Verde" >Cape Verde</option><option value="Central African Republic" >Central African Republic</option><option value="Chad" >Chad</option><option value="Comoros" >Comoros</option><option value="Democratic Republic of the Congo" >Democratic Republic of the Congo</option><option value="Republic of the Congo" >Republic of the Congo</option><option value="Djibouti" >Djibouti</option><option value="Egypt" >Egypt</option><option value="Equatorial Guinea" >Equatorial Guinea</option><option value="Eritrea" >Eritrea</option><option value="Ethiopia" >Ethiopia</option><option value="Gabon" >Gabon</option><option value="Gambia" >Gambia</option><option value="Ghana" >Ghana</option><option value="Gibraltar" >Gibraltar</option><option value="Guinea" >Guinea</option><option value="Guinea-Bissau" >Guinea-Bissau</option><option value="Cote d'Ivoire" >Cote d'Ivoire</option><option value="Kenya" >Kenya</option><option value="Lesotho" >Lesotho</option><option value="Liberia" >Liberia</option><option value="Libya" >Libya</option><option value="Madagascar" >Madagascar</option><option value="Malawi" >Malawi</option><option value="Mali" >Mali</option><option value="Mauritania" >Mauritania</option><option value="Mauritius" >Mauritius</option><option value="Morocco" >Morocco</option><option value="Mozambique" >Mozambique</option><option value="Namibia" >Namibia</option><option value="Niger" >Niger</option><option value="Nigeria" >Nigeria</option><option value="Rwanda" >Rwanda</option><option value="Sao Tome and Principe" >Sao Tome and Principe</option><option value="Senegal" >Senegal</option><option value="Seychelles" >Seychelles</option><option value="Sierra Leone" >Sierra Leone</option><option value="Somalia" >Somalia</option><option value="South Africa" >South Africa</option><option value="Sudan" >Sudan</option><option value="Swaziland" >Swaziland</option><option value="United Republic of Tanzania" >United Republic of Tanzania</option><option value="Togo" >Togo</option><option value="Tunisia" >Tunisia</option><option value="Uganda" >Uganda</option><option value="Zambia" >Zambia</option><option value="Zimbabwe" >Zimbabwe</option></optgroup></select>
<label for="element_16" class="emf-bottom-label">Country / Region</label>
</span>
<div class="emf-clear"></div>
</div></div>
<div class="emf-clear"></div>
</li><li id="emf-li-17" class="emf-li-field emf-field-new_checkbox data_container ">
<label class="emf-label-desc" for="element_17">Jenis Kelamin :</label>
<div class="emf-div-field"><div my_choice_order_type=""><div class="two_column" ><input id="element_17_0" name="element_17[]" value="Laki-laki"
class="validate[optional]" type="checkbox" /><label class="padleft-w5" for="element_17_0">Laki-laki</label></div><div class="two_column" ><input id="element_17_1" name="element_17[]" value="Perempuan"
class="validate[optional]" type="checkbox" /><label class="padleft-w5" for="element_17_1">Perempuan</label></div></div></div>
<div class="emf-clear"></div>
</li><li id="emf-li-18" class="emf-li-field emf-field-text data_container ">
<label class="emf-label-desc" for="element_18">Tempat Lahir :</label>
<div class="emf-div-field"><input id="element_18" name="element_18" value="" size="30" type="text"
class="validate[optional]"/></div>
<div class="emf-clear"></div>
</li><li id="emf-li-19" class="emf-li-field emf-field-datetime data_container ">
<label class="emf-label-desc" for="element_19">Tanggal Lahir :</label>
<div class="emf-div-field"><span class="emf-field-datetime-month">
<input maxlength="2" id="element_19_year-mm" name="element_19_month" value="" class="validate[optional,custom[onlyNumber],length[2,2],lengthValue[1,12]] emf-input-w20" type="text" size="2" />
<label for="element_19_year-mm" class="emf-bottom-label">MM</label>
</span><span class="emf-sep">/</span><span class="emf-field-datetime-day">
<input maxlength="2" id="element_19_year-dd" name="element_19_day" value="" class="validate[optional,custom[onlyNumber],length[2,2],lengthValue[1,31]] emf-input-w20" type="text" size="2" />
<label for="element_19_year-dd" class="emf-bottom-label">DD</label>
</span><span class="emf-sep">/</span><span class="emf-field-datetime-year">
<input maxlength="4" id="element_19_year" name="element_19_year" value="" class="validate[optional,custom[onlyNumber],length[4,4]] emf-input-w40" type="text" size="4" />
<label for="element_19_year" class="emf-bottom-label">YYYY</label>
</span><span>
<input type="hidden" id="element_19_" class="datepicker" my_date_format="mm/dd/yy"/>
</span></div>
<div class="emf-clear"></div>
</li><li id="emf-li-20" class="emf-li-field emf-field-text data_container ">
<label class="emf-label-desc" for="element_20">Agama :</label>
<div class="emf-div-field"><input id="element_20" name="element_20" value="" size="30" type="text"
class="validate[optional]"/></div>
<div class="emf-clear"></div>
</li><li id="emf-li-21" class="emf-li-field emf-field-new_checkbox data_container ">
<label class="emf-label-desc" for="element_21">Kewarganegaraan :</label>
<div class="emf-div-field"><div my_choice_order_type=""><div class="two_column" ><input id="element_21_0" name="element_21[]" value="WNI"
class="validate[optional]" type="checkbox" /><label class="padleft-w5" for="element_21_0">WNI</label></div><div class="two_column" ><input id="element_21_1" name="element_21[]" value="WNA"
class="validate[optional]" type="checkbox" /><label class="padleft-w5" for="element_21_1">WNA</label></div></div></div>
<div class="emf-clear"></div>
</li><li id="emf-li-22" class="emf-li-field emf-field-text data_container ">
<label class="emf-label-desc" for="element_22">Anak ke :</label>
<div class="emf-div-field"><input id="element_22" name="element_22" value="" size="30" type="text"
class="validate[optional]"/></div>
<div class="emf-clear"></div>
</li><li id="emf-li-23" class="emf-li-field emf-field-text data_container ">
<label class="emf-label-desc" for="element_23">Bahasa Sehari-hari :</label>
<div class="emf-div-field"><input id="element_23" name="element_23" value="" size="30" type="text"
class="validate[optional]"/></div>
<div class="emf-clear"></div>
</li><li id="emf-li-24" class="emf-li-field emf-field-text_list data_container ">
<label class="emf-label-desc" for="element_24">Keadaan Jasmani :</label>
<div class="emf-div-field"><table class="emf-field-list" my_statement_order_type="">
<tr class='emf-banding-odd'>
<th>Tinggi badan :</th><td>
<input id="element_25" name="element_25" value="" size="20" type="text"
class="validate[optional]"/></td>
</tr>
<tr class='emf-banding-even'>
<th>Berat badan :</th><td>
<input id="element_26" name="element_26" value="" size="20" type="text"
class="validate[optional]"/></td>
</tr>
<tr class='emf-banding-odd'>
<th>Gol. darah :</th><td>
<input id="element_27" name="element_27" value="" size="20" type="text"
class="validate[optional]"/></td>
</tr>
</table>
</div>
<div class="emf-clear"></div>
</li><li id="emf-li-28" class="emf-li-field emf-field-new_checkbox data_container ">
<label class="emf-label-desc" for="element_28">Bertempat tinggal pada :</label>
<div class="emf-div-field"><div my_choice_order_type=""><div class="two_column" ><input id="element_28_0" name="element_28[]" value="Orang Tua"
class="validate[optional]" type="checkbox" /><label class="padleft-w5" for="element_28_0">Orang Tua</label></div><div class="two_column" ><input id="element_28_1" name="element_28[]" value="Menumpang"
class="validate[optional]" type="checkbox" /><label class="padleft-w5" for="element_28_1">Menumpang</label></div><div class="two_column" ><input id="element_28_2" name="element_28[]" value="Asrama"
class="validate[optional]" type="checkbox" /><label class="padleft-w5" for="element_28_2">Asrama</label></div></div></div>
<div class="emf-clear"></div>
</li><li id="emf-li-29" class="emf-li-field emf-field-text data_container ">
<label class="emf-label-desc" for="element_29">Jarak tempat tinggal ke pangkalan :</label>
<div class="emf-div-field"><input id="element_29" name="element_29" value="" size="30" type="text"
class="validate[optional]"/></div>
<div class="emf-clear"></div>
</li><li id="emf-li-30" class="emf-li-field emf-field-new_checkbox data_container ">
<label class="emf-label-desc" for="element_30">Perjalanan ke Pangkalan</label>
<div class="emf-div-field"><div my_choice_order_type=""><div class="one_column" ><input id="element_30_0" name="element_30[]" value="Jalan Kaki"
class="validate[optional]" type="checkbox" /><label class="padleft-w5" for="element_30_0">Jalan Kaki</label></div><div class="one_column" ><input id="element_30_1" name="element_30[]" value="Naik Kendaraan"
class="validate[optional]" type="checkbox" /><label class="padleft-w5" for="element_30_1">Naik Kendaraan</label></div><div class="one_column" ><input id="element_30_2" name="element_30[]" value="Lain-lain"
class="validate[optional]" type="checkbox" /><label class="padleft-w5" for="element_30_2">Lain-lain</label></div></div></div>
<div class="emf-clear"></div>
</li><li id="emf-li-31" class="emf-li-field emf-field-text data_container ">
<label class="emf-label-desc" for="element_31">Minat / Bakat / Hoby :</label>
<div class="emf-div-field"><input id="element_31" name="element_31" value="" size="30" type="text"
class="validate[optional]"/></div>
<div class="emf-clear"></div>
</li><li id="emf-li-32" class="emf-li-field emf-field-text data_container ">
<label class="emf-label-desc" for="element_32">Pengalaman dalam Kepramukaan :</label>
<div class="emf-div-field"><input id="element_32" name="element_32" value="" size="30" type="text"
class="validate[optional]"/></div>
<div class="emf-clear"></div>
</li><li id="emf-li-33" class="emf-li-field emf-field-text_list data_container ">
<label class="emf-label-desc" for="element_33">Nama Orang Tua/ Wali :</label>
<div class="emf-div-field"><table class="emf-field-list" my_statement_order_type="">
<tr class='emf-banding-odd'>
<th>Ayah</th><td>
<input id="element_34" name="element_34" value="" size="20" type="text"
class="validate[optional]"/></td>
</tr>
<tr class='emf-banding-even'>
<th>Ibu</th><td>
<input id="element_35" name="element_35" value="" size="20" type="text"
class="validate[optional]"/></td>
</tr>
<tr class='emf-banding-odd'>
<th>Wali</th><td>
<input id="element_36" name="element_36" value="" size="20" type="text"
class="validate[optional]"/></td>
</tr>
</table>
</div>
<div class="emf-clear"></div>
</li><li id="emf-li-37" class="emf-li-field emf-field-text_list data_container ">
<label class="emf-label-desc" for="element_37">Umur Orang Tua/ Wali :</label>
<div class="emf-div-field"><table class="emf-field-list" my_statement_order_type="">
<tr class='emf-banding-odd'>
<th>Ayah</th><td>
<input id="element_38" name="element_38" value="" size="20" type="text"
class="validate[optional]"/></td>
</tr>
<tr class='emf-banding-even'>
<th>Ibu</th><td>
<input id="element_39" name="element_39" value="" size="20" type="text"
class="validate[optional]"/></td>
</tr>
<tr class='emf-banding-odd'>
<th>Wali</th><td>
<input id="element_40" name="element_40" value="" size="20" type="text"
class="validate[optional]"/></td>
</tr>
</table>
</div>
<div class="emf-clear"></div>
</li><li id="emf-li-41" class="emf-li-field emf-field-text_list data_container ">
<label class="emf-label-desc" for="element_41">Agama Orang Tua/ Wali :</label>
<div class="emf-div-field"><table class="emf-field-list" my_statement_order_type="">
<tr class='emf-banding-odd'>
<th>Ayah</th><td>
<input id="element_42" name="element_42" value="" size="20" type="text"
class="validate[optional]"/></td>
</tr>
<tr class='emf-banding-even'>
<th>Ibu</th><td>
<input id="element_43" name="element_43" value="" size="20" type="text"
class="validate[optional]"/></td>
</tr>
<tr class='emf-banding-odd'>
<th>Wali</th><td>
<input id="element_44" name="element_44" value="" size="20" type="text"
class="validate[optional]"/></td>
</tr>
</table>
</div>
<div class="emf-clear"></div>
</li><li id="emf-li-45" class="emf-li-field emf-field-text_list data_container ">
<label class="emf-label-desc" for="element_45">Pendidikan Orang Tua/ Wali :</label>
<div class="emf-div-field"><table class="emf-field-list" my_statement_order_type="">
<tr class='emf-banding-odd'>
<th>Ayah</th><td>
<input id="element_46" name="element_46" value="" size="20" type="text"
class="validate[optional]"/></td>
</tr>
<tr class='emf-banding-even'>
<th>Ibu</th><td>
<input id="element_47" name="element_47" value="" size="20" type="text"
class="validate[optional]"/></td>
</tr>
<tr class='emf-banding-odd'>
<th>Wali</th><td>
<input id="element_48" name="element_48" value="" size="20" type="text"
class="validate[optional]"/></td>
</tr>
</table>
</div>
<div class="emf-clear"></div>
</li><li id="emf-li-49" class="emf-li-field emf-field-text_list data_container ">
<label class="emf-label-desc" for="element_49">Pekerjaan Orang Tua/ Wali :</label>
<div class="emf-div-field"><table class="emf-field-list" my_statement_order_type="">
<tr class='emf-banding-odd'>
<th>Ayah</th><td>
<input id="element_50" name="element_50" value="" size="20" type="text"
class="validate[optional]"/></td>
</tr>
<tr class='emf-banding-even'>
<th>Ibu</th><td>
<input id="element_51" name="element_51" value="" size="20" type="text"
class="validate[optional]"/></td>
</tr>
<tr class='emf-banding-odd'>
<th>Wali</th><td>
<input id="element_52" name="element_52" value="" size="20" type="text"
class="validate[optional]"/></td>
</tr>
</table>
</div>
<div class="emf-clear"></div>
</li><li id="emf-li-53" class="emf-li-field emf-field-text data_container ">
<label class="emf-label-desc" for="element_53">Hubungan Wali dengan Keluarga :</label>
<div class="emf-div-field"><input id="element_53" name="element_53" value="" size="30" type="text"
class="validate[optional]"/></div>
<div class="emf-clear"></div>
</li><li id="emf-li-54" class="emf-li-field emf-field-text_list data_container ">
<label class="emf-label-desc" for="element_54">Masuk menjadi anggota Gugusdepan :</label>
<div class="emf-div-field"><table class="emf-field-list" my_statement_order_type="">
<tr class='emf-banding-odd'>
<th>Nama Gudep</th><td>
<input id="element_55" name="element_55" value="" size="20" type="text"
class="validate[optional]"/></td>
</tr>
<tr class='emf-banding-even'>
<th>Diterima tahun</th><td>
<input id="element_56" name="element_56" value="" size="20" type="text"
class="validate[optional]"/></td>
</tr>
<tr class='emf-banding-odd'>
<th>Tingkat</th><td>
<input id="element_57" name="element_57" value="" size="20" type="text"
class="validate[optional]"/></td>
</tr>
</table>
</div>
<div class="emf-clear"></div>
</li><li id="emf-li-58" class="emf-li-field emf-field-text_list data_container ">
<label class="emf-label-desc" for="element_58">Penghargaan yang pernah diraih :</label>
<div class="emf-div-field"><table class="emf-field-list" my_statement_order_type="">
<tr class='emf-banding-odd'>
<th>1. Nama / Tahun</th><td>
<input id="element_59" name="element_59" value="" size="20" type="text"
class="validate[optional]"/></td>
</tr>
<tr class='emf-banding-even'>
<th>2. Nama / Tahun</th><td>
<input id="element_60" name="element_60" value="" size="20" type="text"
class="validate[optional]"/></td>
</tr>
</table>
<div class="emf-div-instruction">Contoh : Pancawarsa I / 2013</div></div>
<div class="emf-clear"></div>
</li><li id="emf-li-61" class="emf-li-field emf-field-text_list data_container ">
<label class="emf-label-desc" for="element_61">Keikutsertaan dalam satuan karya :</label>
<div class="emf-div-field"><table class="emf-field-list" my_statement_order_type="">
<tr class='emf-banding-odd'>
<th>1. Nama / Tahun</th><td>
<input id="element_62" name="element_62" value="" size="20" type="text"
class="validate[optional]"/></td>
</tr>
<tr class='emf-banding-even'>
<th>2. Nama / Tahun</th><td>
<input id="element_63" name="element_63" value="" size="20" type="text"
class="validate[optional]"/></td>
</tr>
</table>
<div class="emf-div-instruction">Contoh : SAKA PARIWISATA / 2013</div></div>
<div class="emf-clear"></div>
</li>
<li id="emf-li-post-button" class="left">
<input value="Submit" type="submit" onmouseover="return true;"/>
</li>
</ul>
<input name="element_counts" value="64" type="hidden" />
<input name="embed" value="forms" type="hidden" /><div style="margin-top:18px;text-align:center"><div id='emf_advertisement'><font face="Verdana" size="2" color="#000000">Powered by</font><span style="position: relative; padding-left: 3px; bottom: -5px;"><img src="//assets.emailmeform.com/images/footer-logo.png?RU1GLTAyLTE4LTEwMzcy" /></span><font face="Verdana" size="2" color="#000000">EMF </font><a style="text-decoration:none;" href="http://www.emailmeform.com/" target="_blank"><font face="Verdana" size="2" color="#000000">Contact Form</font></a></div><div><font face="Verdana" size="2" color="#000000"><a style="line-height:20px;font-size:70%;text-decoration:none;" href="https://www.emailmeform.com/report-abuse.html?http://www.emailmeform.com/builder/form/f2af8F0MAKf" target="_blank">Report Abuse</a></font></div></div>
</form>
</div><img id="emf-form-shadows" src="//assets.emailmeform.com/images/themes/bottom.png?RU1GLTAyLTE4LTEwMzcy"></div>
<script type="text/javascript" src="https://ajax.googleapis.com/ajax/libs/jquery/1.8.3/jquery.min.js"></script>
<script type="text/javascript">
if (typeof jQuery == 'undefined'){
document.write(unescape("%3Cscript src='http://app.emailmeform.com/builder/js/jquery-1.8.3.min.js' type='text/javascript'%3E%3C/script%3E"));
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<script type="text/javascript" src="https://ajax.googleapis.com/ajax/libs/jqueryui/1.7.2/jquery-ui.min.js"></script>
<script type="text/javascript">
if (typeof $.ui == 'undefined'){
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<script type="text/javascript" src="//assets.emailmeform.com/js/dynamic.php?t=post&t2=0&use_CDN=true&language=en&language_id=0&referer_domain=http%3A%2F%2Fwww.emailmeform.com%2F&RU1GLTAyLTE4LTEwMzcy"></script>
<script type="text/javascript">
EMF_jQuery(window).load(function(){
post_message_for_frame_height("f2af8F0MAKf");
});
EMF_jQuery(function(){
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toggle_emf_element(EMF_jQuery('#emf-li-28 .emf-allow-other input'), false);
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toggle_emf_element(EMF_jQuery('#emf-li-30 .emf-allow-other input'), false);
EMF_jQuery('#emf-li-30').find('input:checked, .emf-allow-other input').change();
generate_css_for_emf_ad();
;
EMF_jQuery("#emf-form").validationEngine({
validationEventTriggers:"blur",
scroll:true
});
prevent_duplicate_submission(EMF_jQuery("#emf-form"));
$("input[emf_mask_input=true]").dPassword();
if(EMF_jQuery('#captcha_image').length>0){
on_captcha_image_load();
}
EMF_jQuery('.emf-field-grid td').click(function(event){
if(!event.target.tagName || event.target.tagName.toLowerCase()!='td') return;
EMF_jQuery(this).find('input[type=checkbox],input[type=radio]').click();
});
build_datepicker();
EMF_jQuery("#emf-form ul li").mousedown(highlight_field_on_mousedown);
EMF_jQuery("#emf-form ul li input, #emf-form ul li textarea, #emf-form ul li select").focus(highlight_field_on_focus);
var form_obj=EMF_jQuery("#emf-container form");
if(form_obj.length>0 && form_obj.attr('action').indexOf('#')==-1 && window.location.hash){
form_obj.attr('action', form_obj.attr('action')+window.location.hash);
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function(index){
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function(index){
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function(index){
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$("input[id^=element_"+index+"_]").each(function(){
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function(index){
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,Image :
function(index){
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,price :
function(index){
var result="";
var arr=new Array();
$("input[id^=element_"+index+"_]").each(function(){
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});
result=arr.join(".");
return result;
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,hidden :
function(index){
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}
,unique_id :
function(index){
return $("#element_"+index).val();
}
,section_break :
function(index){
return "";
}
,page_break :
function(index){
return "";
}
,signature :
function(index){
return $("#element_"+index).val();
}
,star_rating :
function(index){
var result="";
$("input[name=element_"+index+"]:checked").each(function(){
result=this.value;
});
return result;
}
,scale_rating :
function(index){
var result="";
$("input[name=element_"+index+"]:checked").each(function(){
result=this.value;
});
return result;
}
,deprecated :
function(index){
return $("#element_"+index).val();
}
,address :
function(index){
var result="";
var element_arr=$("input,select").filter("[name='element_"+index+"[]']").toArray();
result=element_arr[0].value+" "+element_arr[1].value+"\n"
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,name :
function(index){
var arr=new Array();
$("input[id^=element_"+index+"_]").each(function(){
arr[arr.length]=this.value;
});
var result=arr.join(" ");
return result;
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,checkbox :
function(index){
var arr=new Array();
$("input[name='element_"+index+"[]']:checked").each(function(){
arr[arr.length]=this.value;
});
var result=arr.join(", ");
return result;
}
,select_multiple :
function(index){
return $("#element_"+index).val();
}
};
var emf_condition_id_to_js_map={5 :
function(field_value, value){
return field_value==value;
}
,6 :
function(field_value, value){
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}
,1 :
function(field_value, value){
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function(field_value, value){
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function(field_value, value){
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function(field_value, value){
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return false;
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var date_for_value=Date.parse(value);
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function(field_value, value){
var date_for_field_value=Date.parse(field_value);
var date_for_value=Date.parse(value);
if(date_for_field_value && date_for_value){
return date_for_field_value > date_for_value;
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return false;
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};
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var emf_group_to_page_rules_for_confirmation_map=[];
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var emf_page_info={current_page_index: 0, page_element_index_min: 0, page_element_index_max: 63};
var emf_index_to_value_map=null;
var emf_form_visit_id="f2af8F0MAKf";
var emf_index_to_option_map=[];
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<meta name="viewport" content="width=device-width, initial-scale=1">
<link rel="stylesheet" type="text/css" href="//assets.emailmeform.com/styles/dynamic.php?t=post&enable_responsive_ui=1&RU1GLTAyLTE4LTEwMzcy" />
<link rel="stylesheet" type="text/css" href="http://app.emailmeform.com/builder/theme_css/f2af8F0MAKf" />
<style>
#emf-container, #emf-container-outer #emf-form-shadows{box-sizing: border-box;-webkit-box-sizing: border-box;-moz-box-sizing: border-box;width:640px}
@media screen and (max-width: 656px) {#emf-container,#emf-container-outer #emf-form-shadows {width: 100%;} }
</style>
<div id="emf-container-outer">
<div id="emf-container" >
<div id="emf-logo"><a>EmailMeForm</a></div>
<div class="emf-error-message" style='display:none'></div>
<form id="emf-form" target="_self" class="leftLabel" enctype="multipart/form-data" method="post" action="http://www.emailmeform.com/builder/form/f2af8F0MAKf"><div id="emf-form-instruction" class="emf-head-widget">
<div id="emf-form-title" class="emf-bold">Registrasi Buku Induk</div><div id="emf-form-description"></div>
</div>
<ul>
<li id="emf-li-0" class="emf-li-field emf-field-number data_container ">
<label class="emf-label-desc" for="element_0">Nomor Induk Siswa :</label>
<div class="emf-div-field"><input id="element_0" name="element_0"
class="validate[optional,custom[extNumber]]"
value="" size="30" type="text" /></div>
<div class="emf-clear"></div>
</li><li id="emf-li-1" class="emf-li-field emf-field-number data_container ">
<label class="emf-label-desc" for="element_1">Nomor Tanda Anggota :</label>
<div class="emf-div-field"><input id="element_1" name="element_1"
class="validate[optional,custom[extNumber]]"
value="" size="30" type="text" /></div>
<div class="emf-clear"></div>
</li><li id="emf-li-2" class="emf-li-field emf-field-file data_container ">
<label class="emf-label-desc" for="element_2">Foto</label>
<div class="emf-div-field"><input id="element_2" name="element_2" onchange="EMF_jQuery(this).blur()"
class="validate[optional,funcCall[check_file_error[null,2M]]]" type="file" /><div class="emf-div-instruction">Foto 3x4 menggunkan seragam sekolah</div></div>
<div class="emf-clear"></div>
</li><li id="emf-li-3" class="emf-li-field emf-field-new_name data_container ">
<label class="emf-label-desc" for="element_3">Nama :</label>
<div class="emf-div-field"><span style="width:60px">
<input class="validate[optional]" style="width:100%" value=""
id="element_5" name="element_5" type="text" />
<label for="element_5" class="emf-bottom-label emf-text-center">First</label>
</span><span style="width:100px">
<input class="validate[optional]" style="width:100%" value=""
id="element_6" name="element_6" type="text" />
<label for="element_6" class="emf-bottom-label emf-text-center">Last</label>
</span><div class="emf-div-instruction">Nama Lengkap!</div></div>
<div class="emf-clear"></div>
</li><li id="emf-li-10" class="emf-li-field emf-field-new_address data_container ">
<label class="emf-label-desc" for="element_10">Alamat :</label>
<div class="emf-div-field">
<div style="width:99%;">
<span class="emf-full emf-field-new_address-addr1">
<input type="text" value="" id="element_11" name="element_11" class="emf-full validate[optional]" />
<label for="element_11" class="emf-bottom-label">Street Address</label>
</span>
<span class="emf-left emf-half emf-field-new_address-city">
<input type="text" value="" id="element_13" name="element_13" class="emf-full validate[optional]" />
<label for="element_13" class="emf-bottom-label">City</label>
</span>
<span class="emf-right emf-half emf-field-new_address-state">
<input type="text" value="" id="element_14" name="element_14" class="emf-full validate[optional]" />
<label for="element_14" class="emf-bottom-label">State / Province / Region</label>
</span>
<span class="emf-left emf-half emf-field-new_address-zipcode">
<input type="text" value="" id="element_15" name="element_15" class="emf-full validate[optional]" />
<label for="element_15" class="emf-bottom-label">Postal / Zip Code</label>
</span>
<span class="emf-right emf-half emf-field-new_address-country">
<select id="element_16" name="element_16" class="emf-address validate[optional]">
<option value=''> </option><optgroup label="North America"><option value="Antigua and Barbuda" >Antigua and Barbuda</option><option value="Aruba" >Aruba</option><option value="Bahamas" >Bahamas</option><option value="Barbados" >Barbados</option><option value="Belize" >Belize</option><option value="Canada" >Canada</option><option value="Cayman Islands" >Cayman Islands</option><option value="Cook Islands" >Cook Islands</option><option value="Costa Rica" >Costa Rica</option><option value="Cuba" >Cuba</option><option value="Dominica" >Dominica</option><option value="Dominican Republic" >Dominican Republic</option><option value="El Salvador" >El Salvador</option><option value="Grenada" >Grenada</option><option value="Guatemala" >Guatemala</option><option value="Haiti" >Haiti</option><option value="Honduras" >Honduras</option><option value="Jamaica" >Jamaica</option><option value="Mexico" >Mexico</option><option value="Netherlands Antilles" >Netherlands Antilles</option><option value="Nicaragua" >Nicaragua</option><option value="Panama " >Panama </option><option value="Puerto Rico " >Puerto Rico </option><option value="Saint Kitts and Nevis" >Saint Kitts and Nevis</option><option value="Saint Lucia" >Saint Lucia</option><option value="Saint Vincent and the Grenadines" >Saint Vincent and the Grenadines</option><option value="Trinidad and Tobago" >Trinidad and Tobago</option><option value="United States" >United States</option></optgroup><optgroup label="South America"><option value="Argentina" >Argentina</option><option value="Bolivia" >Bolivia</option><option value="Brazil" >Brazil</option><option value="Chile" >Chile</option><option value="Colombia" >Colombia</option><option value="Ecuador" >Ecuador</option><option value="Guyana" >Guyana</option><option value="Paraguay" >Paraguay</option><option value="Peru" >Peru</option><option value="Suriname" >Suriname</option><option value="Uruguay" >Uruguay</option><option value="Venezuela" >Venezuela</option></optgroup><optgroup label="Europe"><option value="Albania" >Albania</option><option value="Andorra" >Andorra</option><option value="Armenia" >Armenia</option><option value="Austria" >Austria</option><option value="Azerbaijan" >Azerbaijan</option><option value="Belarus" >Belarus</option><option value="Belgium" >Belgium</option><option value="Bosnia and Herzegovina" >Bosnia and Herzegovina</option><option value="Bulgaria" >Bulgaria</option><option value="Croatia" >Croatia</option><option value="Cyprus" >Cyprus</option><option value="Czech Republic" >Czech Republic</option><option value="Denmark" >Denmark</option><option value="Estonia" >Estonia</option><option value="Faroe Islands" >Faroe Islands</option><option value="Finland" >Finland</option><option value="France" >France</option><option value="Georgia" >Georgia</option><option value="Germany" >Germany</option><option value="Greece" >Greece</option><option value="Hungary" >Hungary</option><option value="Iceland" >Iceland</option><option value="Ireland" >Ireland</option><option value="Italy" >Italy</option><option value="Kosovo" >Kosovo</option><option value="Latvia" >Latvia</option><option value="Liechtenstein" >Liechtenstein</option><option value="Lithuania" >Lithuania</option><option value="Luxembourg" >Luxembourg</option><option value="Macedonia" >Macedonia</option><option value="Malta" >Malta</option><option value="Moldova" >Moldova</option><option value="Monaco" >Monaco</option><option value="Montenegro" >Montenegro</option><option value="Netherlands" >Netherlands</option><option value="Norway" >Norway</option><option value="Poland" >Poland</option><option value="Portugal" >Portugal</option><option value="Romania" >Romania</option><option value="San Marino" >San Marino</option><option value="Serbia" >Serbia</option><option value="Slovakia" >Slovakia</option><option value="Slovenia" >Slovenia</option><option value="Spain" >Spain</option><option value="Sweden" >Sweden</option><option value="Switzerland" >Switzerland</option><option value="Ukraine" >Ukraine</option><option value="United Kingdom" >United Kingdom</option><option value="Vatican City" >Vatican City</option></optgroup><optgroup label="Asia"><option value="Afghanistan" >Afghanistan</option><option value="Bahrain" >Bahrain</option><option value="Bangladesh" >Bangladesh</option><option value="Bhutan" >Bhutan</option><option value="Brunei Darussalam" >Brunei Darussalam</option><option value="Myanmar" >Myanmar</option><option value="Cambodia" >Cambodia</option><option value="China" >China</option><option value="East Timor" >East Timor</option><option value="Hong Kong" >Hong Kong</option><option value="India" >India</option><option value="Indonesia" >Indonesia</option><option value="Iran" >Iran</option><option value="Iraq" >Iraq</option><option value="Israel" >Israel</option><option value="Japan" >Japan</option><option value="Jordan" >Jordan</option><option value="Kazakhstan" >Kazakhstan</option><option value="North Korea" >North Korea</option><option value="South Korea" >South Korea</option><option value="Kuwait" >Kuwait</option><option value="Kyrgyzstan" >Kyrgyzstan</option><option value="Laos" >Laos</option><option value="Lebanon" >Lebanon</option><option value="Malaysia" >Malaysia</option><option value="Maldives" >Maldives</option><option value="Mongolia" >Mongolia</option><option value="Nepal" >Nepal</option><option value="Oman" >Oman</option><option value="Pakistan" >Pakistan</option><option value="Palestine" >Palestine</option><option value="Philippines" >Philippines</option><option value="Qatar" >Qatar</option><option value="Russia" >Russia</option><option value="Saudi Arabia" >Saudi Arabia</option><option value="Singapore" >Singapore</option><option value="Sri Lanka" >Sri Lanka</option><option value="Syria" >Syria</option><option value="Taiwan" >Taiwan</option><option value="Tajikistan" >Tajikistan</option><option value="Thailand" >Thailand</option><option value="Turkey" >Turkey</option><option value="Turkmenistan" >Turkmenistan</option><option value="United Arab Emirates" >United Arab Emirates</option><option value="Uzbekistan" >Uzbekistan</option><option value="Vietnam" >Vietnam</option><option value="Yemen" >Yemen</option></optgroup><optgroup label="Oceania"><option value="Australia" >Australia</option><option value="Fiji" >Fiji</option><option value="Kiribati" >Kiribati</option><option value="Marshall Islands" >Marshall Islands</option><option value="Micronesia" >Micronesia</option><option value="Nauru" >Nauru</option><option value="New Zealand" >New Zealand</option><option value="Palau" >Palau</option><option value="Papua New Guinea" >Papua New Guinea</option><option value="Samoa" >Samoa</option><option value="Solomon Islands" >Solomon Islands</option><option value="Tonga" >Tonga</option><option value="Tuvalu" >Tuvalu</option><option value="Vanuatu" >Vanuatu</option></optgroup><optgroup label="Africa"><option value="Algeria" >Algeria</option><option value="Angola" >Angola</option><option value="Benin" >Benin</option><option value="Botswana" >Botswana</option><option value="Burkina Faso" >Burkina Faso</option><option value="Burundi" >Burundi</option><option value="Cameroon" >Cameroon</option><option value="Cape Verde" >Cape Verde</option><option value="Central African Republic" >Central African Republic</option><option value="Chad" >Chad</option><option value="Comoros" >Comoros</option><option value="Democratic Republic of the Congo" >Democratic Republic of the Congo</option><option value="Republic of the Congo" >Republic of the Congo</option><option value="Djibouti" >Djibouti</option><option value="Egypt" >Egypt</option><option value="Equatorial Guinea" >Equatorial Guinea</option><option value="Eritrea" >Eritrea</option><option value="Ethiopia" >Ethiopia</option><option value="Gabon" >Gabon</option><option value="Gambia" >Gambia</option><option value="Ghana" >Ghana</option><option value="Gibraltar" >Gibraltar</option><option value="Guinea" >Guinea</option><option value="Guinea-Bissau" >Guinea-Bissau</option><option value="Cote d'Ivoire" >Cote d'Ivoire</option><option value="Kenya" >Kenya</option><option value="Lesotho" >Lesotho</option><option value="Liberia" >Liberia</option><option value="Libya" >Libya</option><option value="Madagascar" >Madagascar</option><option value="Malawi" >Malawi</option><option value="Mali" >Mali</option><option value="Mauritania" >Mauritania</option><option value="Mauritius" >Mauritius</option><option value="Morocco" >Morocco</option><option value="Mozambique" >Mozambique</option><option value="Namibia" >Namibia</option><option value="Niger" >Niger</option><option value="Nigeria" >Nigeria</option><option value="Rwanda" >Rwanda</option><option value="Sao Tome and Principe" >Sao Tome and Principe</option><option value="Senegal" >Senegal</option><option value="Seychelles" >Seychelles</option><option value="Sierra Leone" >Sierra Leone</option><option value="Somalia" >Somalia</option><option value="South Africa" >South Africa</option><option value="Sudan" >Sudan</option><option value="Swaziland" >Swaziland</option><option value="United Republic of Tanzania" >United Republic of Tanzania</option><option value="Togo" >Togo</option><option value="Tunisia" >Tunisia</option><option value="Uganda" >Uganda</option><option value="Zambia" >Zambia</option><option value="Zimbabwe" >Zimbabwe</option></optgroup></select>
<label for="element_16" class="emf-bottom-label">Country / Region</label>
</span>
<div class="emf-clear"></div>
</div></div>
<div class="emf-clear"></div>
</li><li id="emf-li-17" class="emf-li-field emf-field-new_checkbox data_container ">
<label class="emf-label-desc" for="element_17">Jenis Kelamin :</label>
<div class="emf-div-field"><div my_choice_order_type=""><div class="two_column" ><input id="element_17_0" name="element_17[]" value="Laki-laki"
class="validate[optional]" type="checkbox" /><label class="padleft-w5" for="element_17_0">Laki-laki</label></div><div class="two_column" ><input id="element_17_1" name="element_17[]" value="Perempuan"
class="validate[optional]" type="checkbox" /><label class="padleft-w5" for="element_17_1">Perempuan</label></div></div></div>
<div class="emf-clear"></div>
</li><li id="emf-li-18" class="emf-li-field emf-field-text data_container ">
<label class="emf-label-desc" for="element_18">Tempat Lahir :</label>
<div class="emf-div-field"><input id="element_18" name="element_18" value="" size="30" type="text"
class="validate[optional]"/></div>
<div class="emf-clear"></div>
</li><li id="emf-li-19" class="emf-li-field emf-field-datetime data_container ">
<label class="emf-label-desc" for="element_19">Tanggal Lahir :</label>
<div class="emf-div-field"><span class="emf-field-datetime-month">
<input maxlength="2" id="element_19_year-mm" name="element_19_month" value="" class="validate[optional,custom[onlyNumber],length[2,2],lengthValue[1,12]] emf-input-w20" type="text" size="2" />
<label for="element_19_year-mm" class="emf-bottom-label">MM</label>
</span><span class="emf-sep">/</span><span class="emf-field-datetime-day">
<input maxlength="2" id="element_19_year-dd" name="element_19_day" value="" class="validate[optional,custom[onlyNumber],length[2,2],lengthValue[1,31]] emf-input-w20" type="text" size="2" />
<label for="element_19_year-dd" class="emf-bottom-label">DD</label>
</span><span class="emf-sep">/</span><span class="emf-field-datetime-year">
<input maxlength="4" id="element_19_year" name="element_19_year" value="" class="validate[optional,custom[onlyNumber],length[4,4]] emf-input-w40" type="text" size="4" />
<label for="element_19_year" class="emf-bottom-label">YYYY</label>
</span><span>
<input type="hidden" id="element_19_" class="datepicker" my_date_format="mm/dd/yy"/>
</span></div>
<div class="emf-clear"></div>
</li><li id="emf-li-20" class="emf-li-field emf-field-text data_container ">
<label class="emf-label-desc" for="element_20">Agama :</label>
<div class="emf-div-field"><input id="element_20" name="element_20" value="" size="30" type="text"
class="validate[optional]"/></div>
<div class="emf-clear"></div>
</li><li id="emf-li-21" class="emf-li-field emf-field-new_checkbox data_container ">
<label class="emf-label-desc" for="element_21">Kewarganegaraan :</label>
<div class="emf-div-field"><div my_choice_order_type=""><div class="two_column" ><input id="element_21_0" name="element_21[]" value="WNI"
class="validate[optional]" type="checkbox" /><label class="padleft-w5" for="element_21_0">WNI</label></div><div class="two_column" ><input id="element_21_1" name="element_21[]" value="WNA"
class="validate[optional]" type="checkbox" /><label class="padleft-w5" for="element_21_1">WNA</label></div></div></div>
<div class="emf-clear"></div>
</li><li id="emf-li-22" class="emf-li-field emf-field-text data_container ">
<label class="emf-label-desc" for="element_22">Anak ke :</label>
<div class="emf-div-field"><input id="element_22" name="element_22" value="" size="30" type="text"
class="validate[optional]"/></div>
<div class="emf-clear"></div>
</li><li id="emf-li-23" class="emf-li-field emf-field-text data_container ">
<label class="emf-label-desc" for="element_23">Bahasa Sehari-hari :</label>
<div class="emf-div-field"><input id="element_23" name="element_23" value="" size="30" type="text"
class="validate[optional]"/></div>
<div class="emf-clear"></div>
</li><li id="emf-li-24" class="emf-li-field emf-field-text_list data_container ">
<label class="emf-label-desc" for="element_24">Keadaan Jasmani :</label>
<div class="emf-div-field"><table class="emf-field-list" my_statement_order_type="">
<tr class='emf-banding-odd'>
<th>Tinggi badan :</th><td>
<input id="element_25" name="element_25" value="" size="20" type="text"
class="validate[optional]"/></td>
</tr>
<tr class='emf-banding-even'>
<th>Berat badan :</th><td>
<input id="element_26" name="element_26" value="" size="20" type="text"
class="validate[optional]"/></td>
</tr>
<tr class='emf-banding-odd'>
<th>Gol. darah :</th><td>
<input id="element_27" name="element_27" value="" size="20" type="text"
class="validate[optional]"/></td>
</tr>
</table>
</div>
<div class="emf-clear"></div>
</li><li id="emf-li-28" class="emf-li-field emf-field-new_checkbox data_container ">
<label class="emf-label-desc" for="element_28">Bertempat tinggal pada :</label>
<div class="emf-div-field"><div my_choice_order_type=""><div class="two_column" ><input id="element_28_0" name="element_28[]" value="Orang Tua"
class="validate[optional]" type="checkbox" /><label class="padleft-w5" for="element_28_0">Orang Tua</label></div><div class="two_column" ><input id="element_28_1" name="element_28[]" value="Menumpang"
class="validate[optional]" type="checkbox" /><label class="padleft-w5" for="element_28_1">Menumpang</label></div><div class="two_column" ><input id="element_28_2" name="element_28[]" value="Asrama"
class="validate[optional]" type="checkbox" /><label class="padleft-w5" for="element_28_2">Asrama</label></div></div></div>
<div class="emf-clear"></div>
</li><li id="emf-li-29" class="emf-li-field emf-field-text data_container ">
<label class="emf-label-desc" for="element_29">Jarak tempat tinggal ke pangkalan :</label>
<div class="emf-div-field"><input id="element_29" name="element_29" value="" size="30" type="text"
class="validate[optional]"/></div>
<div class="emf-clear"></div>
</li><li id="emf-li-30" class="emf-li-field emf-field-new_checkbox data_container ">
<label class="emf-label-desc" for="element_30">Perjalanan ke Pangkalan</label>
<div class="emf-div-field"><div my_choice_order_type=""><div class="one_column" ><input id="element_30_0" name="element_30[]" value="Jalan Kaki"
class="validate[optional]" type="checkbox" /><label class="padleft-w5" for="element_30_0">Jalan Kaki</label></div><div class="one_column" ><input id="element_30_1" name="element_30[]" value="Naik Kendaraan"
class="validate[optional]" type="checkbox" /><label class="padleft-w5" for="element_30_1">Naik Kendaraan</label></div><div class="one_column" ><input id="element_30_2" name="element_30[]" value="Lain-lain"
class="validate[optional]" type="checkbox" /><label class="padleft-w5" for="element_30_2">Lain-lain</label></div></div></div>
<div class="emf-clear"></div>
</li><li id="emf-li-31" class="emf-li-field emf-field-text data_container ">
<label class="emf-label-desc" for="element_31">Minat / Bakat / Hoby :</label>
<div class="emf-div-field"><input id="element_31" name="element_31" value="" size="30" type="text"
class="validate[optional]"/></div>
<div class="emf-clear"></div>
</li><li id="emf-li-32" class="emf-li-field emf-field-text data_container ">
<label class="emf-label-desc" for="element_32">Pengalaman dalam Kepramukaan :</label>
<div class="emf-div-field"><input id="element_32" name="element_32" value="" size="30" type="text"
class="validate[optional]"/></div>
<div class="emf-clear"></div>
</li><li id="emf-li-33" class="emf-li-field emf-field-text_list data_container ">
<label class="emf-label-desc" for="element_33">Nama Orang Tua/ Wali :</label>
<div class="emf-div-field"><table class="emf-field-list" my_statement_order_type="">
<tr class='emf-banding-odd'>
<th>Ayah</th><td>
<input id="element_34" name="element_34" value="" size="20" type="text"
class="validate[optional]"/></td>
</tr>
<tr class='emf-banding-even'>
<th>Ibu</th><td>
<input id="element_35" name="element_35" value="" size="20" type="text"
class="validate[optional]"/></td>
</tr>
<tr class='emf-banding-odd'>
<th>Wali</th><td>
<input id="element_36" name="element_36" value="" size="20" type="text"
class="validate[optional]"/></td>
</tr>
</table>
</div>
<div class="emf-clear"></div>
</li><li id="emf-li-37" class="emf-li-field emf-field-text_list data_container ">
<label class="emf-label-desc" for="element_37">Umur Orang Tua/ Wali :</label>
<div class="emf-div-field"><table class="emf-field-list" my_statement_order_type="">
<tr class='emf-banding-odd'>
<th>Ayah</th><td>
<input id="element_38" name="element_38" value="" size="20" type="text"
class="validate[optional]"/></td>
</tr>
<tr class='emf-banding-even'>
<th>Ibu</th><td>
<input id="element_39" name="element_39" value="" size="20" type="text"
class="validate[optional]"/></td>
</tr>
<tr class='emf-banding-odd'>
<th>Wali</th><td>
<input id="element_40" name="element_40" value="" size="20" type="text"
class="validate[optional]"/></td>
</tr>
</table>
</div>
<div class="emf-clear"></div>
</li><li id="emf-li-41" class="emf-li-field emf-field-text_list data_container ">
<label class="emf-label-desc" for="element_41">Agama Orang Tua/ Wali :</label>
<div class="emf-div-field"><table class="emf-field-list" my_statement_order_type="">
<tr class='emf-banding-odd'>
<th>Ayah</th><td>
<input id="element_42" name="element_42" value="" size="20" type="text"
class="validate[optional]"/></td>
</tr>
<tr class='emf-banding-even'>
<th>Ibu</th><td>
<input id="element_43" name="element_43" value="" size="20" type="text"
class="validate[optional]"/></td>
</tr>
<tr class='emf-banding-odd'>
<th>Wali</th><td>
<input id="element_44" name="element_44" value="" size="20" type="text"
class="validate[optional]"/></td>
</tr>
</table>
</div>
<div class="emf-clear"></div>
</li><li id="emf-li-45" class="emf-li-field emf-field-text_list data_container ">
<label class="emf-label-desc" for="element_45">Pendidikan Orang Tua/ Wali :</label>
<div class="emf-div-field"><table class="emf-field-list" my_statement_order_type="">
<tr class='emf-banding-odd'>
<th>Ayah</th><td>
<input id="element_46" name="element_46" value="" size="20" type="text"
class="validate[optional]"/></td>
</tr>
<tr class='emf-banding-even'>
<th>Ibu</th><td>
<input id="element_47" name="element_47" value="" size="20" type="text"
class="validate[optional]"/></td>
</tr>
<tr class='emf-banding-odd'>
<th>Wali</th><td>
<input id="element_48" name="element_48" value="" size="20" type="text"
class="validate[optional]"/></td>
</tr>
</table>
</div>
<div class="emf-clear"></div>
</li><li id="emf-li-49" class="emf-li-field emf-field-text_list data_container ">
<label class="emf-label-desc" for="element_49">Pekerjaan Orang Tua/ Wali :</label>
<div class="emf-div-field"><table class="emf-field-list" my_statement_order_type="">
<tr class='emf-banding-odd'>
<th>Ayah</th><td>
<input id="element_50" name="element_50" value="" size="20" type="text"
class="validate[optional]"/></td>
</tr>
<tr class='emf-banding-even'>
<th>Ibu</th><td>
<input id="element_51" name="element_51" value="" size="20" type="text"
class="validate[optional]"/></td>
</tr>
<tr class='emf-banding-odd'>
<th>Wali</th><td>
<input id="element_52" name="element_52" value="" size="20" type="text"
class="validate[optional]"/></td>
</tr>
</table>
</div>
<div class="emf-clear"></div>
</li><li id="emf-li-53" class="emf-li-field emf-field-text data_container ">
<label class="emf-label-desc" for="element_53">Hubungan Wali dengan Keluarga :</label>
<div class="emf-div-field"><input id="element_53" name="element_53" value="" size="30" type="text"
class="validate[optional]"/></div>
<div class="emf-clear"></div>
</li><li id="emf-li-54" class="emf-li-field emf-field-text_list data_container ">
<label class="emf-label-desc" for="element_54">Masuk menjadi anggota Gugusdepan :</label>
<div class="emf-div-field"><table class="emf-field-list" my_statement_order_type="">
<tr class='emf-banding-odd'>
<th>Nama Gudep</th><td>
<input id="element_55" name="element_55" value="" size="20" type="text"
class="validate[optional]"/></td>
</tr>
<tr class='emf-banding-even'>
<th>Diterima tahun</th><td>
<input id="element_56" name="element_56" value="" size="20" type="text"
class="validate[optional]"/></td>
</tr>
<tr class='emf-banding-odd'>
<th>Tingkat</th><td>
<input id="element_57" name="element_57" value="" size="20" type="text"
class="validate[optional]"/></td>
</tr>
</table>
</div>
<div class="emf-clear"></div>
</li><li id="emf-li-58" class="emf-li-field emf-field-text_list data_container ">
<label class="emf-label-desc" for="element_58">Penghargaan yang pernah diraih :</label>
<div class="emf-div-field"><table class="emf-field-list" my_statement_order_type="">
<tr class='emf-banding-odd'>
<th>1. Nama / Tahun</th><td>
<input id="element_59" name="element_59" value="" size="20" type="text"
class="validate[optional]"/></td>
</tr>
<tr class='emf-banding-even'>
<th>2. Nama / Tahun</th><td>
<input id="element_60" name="element_60" value="" size="20" type="text"
class="validate[optional]"/></td>
</tr>
</table>
<div class="emf-div-instruction">Contoh : Pancawarsa I / 2013</div></div>
<div class="emf-clear"></div>
</li><li id="emf-li-61" class="emf-li-field emf-field-text_list data_container ">
<label class="emf-label-desc" for="element_61">Keikutsertaan dalam satuan karya :</label>
<div class="emf-div-field"><table class="emf-field-list" my_statement_order_type="">
<tr class='emf-banding-odd'>
<th>1. Nama / Tahun</th><td>
<input id="element_62" name="element_62" value="" size="20" type="text"
class="validate[optional]"/></td>
</tr>
<tr class='emf-banding-even'>
<th>2. Nama / Tahun</th><td>
<input id="element_63" name="element_63" value="" size="20" type="text"
class="validate[optional]"/></td>
</tr>
</table>
<div class="emf-div-instruction">Contoh : SAKA PARIWISATA / 2013</div></div>
<div class="emf-clear"></div>
</li>
<li id="emf-li-post-button" class="left">
<input value="Submit" type="submit" onmouseover="return true;"/>
</li>
</ul>
<input name="element_counts" value="64" type="hidden" />
<input name="embed" value="forms" type="hidden" /><div style="margin-top:18px;text-align:center"><div id='emf_advertisement'><font face="Verdana" size="2" color="#000000">Powered by</font><span style="position: relative; padding-left: 3px; bottom: -5px;"><img src="//assets.emailmeform.com/images/footer-logo.png?RU1GLTAyLTE4LTEwMzcy" /></span><font face="Verdana" size="2" color="#000000">EMF </font><a style="text-decoration:none;" href="http://www.emailmeform.com/" target="_blank"><font face="Verdana" size="2" color="#000000">Contact Form</font></a></div><div><font face="Verdana" size="2" color="#000000"><a style="line-height:20px;font-size:70%;text-decoration:none;" href="https://www.emailmeform.com/report-abuse.html?http://www.emailmeform.com/builder/form/f2af8F0MAKf" target="_blank">Report Abuse</a></font></div></div>
</form>
</div><img id="emf-form-shadows" src="//assets.emailmeform.com/images/themes/bottom.png?RU1GLTAyLTE4LTEwMzcy"></div>
<script type="text/javascript" src="https://ajax.googleapis.com/ajax/libs/jquery/1.8.3/jquery.min.js"></script>
<script type="text/javascript">
if (typeof jQuery == 'undefined'){
document.write(unescape("%3Cscript src='http://app.emailmeform.com/builder/js/jquery-1.8.3.min.js' type='text/javascript'%3E%3C/script%3E"));
}
</script>
<script type="text/javascript" src="https://ajax.googleapis.com/ajax/libs/jqueryui/1.7.2/jquery-ui.min.js"></script>
<script type="text/javascript">
if (typeof $.ui == 'undefined'){
document.write(unescape("%3Cscript src='http://app.emailmeform.com/builder/js/jquery-ui-1.7.2.custom.min.js' type='text/javascript'%3E%3C/script%3E"));
}
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<script type="text/javascript" src="//assets.emailmeform.com/js/dynamic.php?t=post&t2=0&use_CDN=true&language=en&language_id=0&referer_domain=http%3A%2F%2Fwww.emailmeform.com%2F&RU1GLTAyLTE4LTEwMzcy"></script>
<script type="text/javascript">
EMF_jQuery(window).load(function(){
post_message_for_frame_height("f2af8F0MAKf");
});
EMF_jQuery(function(){
toggle_emf_element(EMF_jQuery('#emf-li-17 .emf-allow-other input'), false);
EMF_jQuery('#emf-li-17').find('input:checked, .emf-allow-other input').change();
bind_auto_cursor(EMF_jQuery('#emf-li-19 :input'));
toggle_emf_element(EMF_jQuery('#emf-li-21 .emf-allow-other input'), false);
EMF_jQuery('#emf-li-21').find('input:checked, .emf-allow-other input').change();
toggle_emf_element(EMF_jQuery('#emf-li-28 .emf-allow-other input'), false);
EMF_jQuery('#emf-li-28').find('input:checked, .emf-allow-other input').change();
toggle_emf_element(EMF_jQuery('#emf-li-30 .emf-allow-other input'), false);
EMF_jQuery('#emf-li-30').find('input:checked, .emf-allow-other input').change();
generate_css_for_emf_ad();
;
EMF_jQuery("#emf-form").validationEngine({
validationEventTriggers:"blur",
scroll:true
});
prevent_duplicate_submission(EMF_jQuery("#emf-form"));
$("input[emf_mask_input=true]").dPassword();
if(EMF_jQuery('#captcha_image').length>0){
on_captcha_image_load();
}
EMF_jQuery('.emf-field-grid td').click(function(event){
if(!event.target.tagName || event.target.tagName.toLowerCase()!='td') return;
EMF_jQuery(this).find('input[type=checkbox],input[type=radio]').click();
});
build_datepicker();
EMF_jQuery("#emf-form ul li").mousedown(highlight_field_on_mousedown);
EMF_jQuery("#emf-form ul li input, #emf-form ul li textarea, #emf-form ul li select").focus(highlight_field_on_focus);
var form_obj=EMF_jQuery("#emf-container form");
if(form_obj.length>0 && form_obj.attr('action').indexOf('#')==-1 && window.location.hash){
form_obj.attr('action', form_obj.attr('action')+window.location.hash);
}
init_rules();
enable_session_when_cookie_disabled();
detect_unsupported_browser();
randomize_field_content();
});
var emf_widgets={text :
function(index){
return $("#element_"+index).val();
}
,number :
function(index){
return $("#element_"+index).val();
}
,textarea :
function(index){
return $("#element_"+index).val();
}
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function(index){
var arr=new Array();
$("input[name='element_"+index+"[]']:checked").each(function(){
arr[arr.length]=this.value;
});
var result=arr.join(", ");
return result;
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function(index){
var result="";
$("input[name=element_"+index+"]:checked").each(function(){
result=this.value;
});
return result;
}
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function(index){
return $("#element_"+index).val();
}
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function(index){
return $("#element_"+index).val();
}
,phone :
function(index){
var arr=new Array();
$("input[id^=element_"+index+"_]").each(function(){
arr[arr.length]=this.value;
});
var result="";
if(arr.length>0){
result=arr.join("-");
}else{
result=$("#element_"+index).val();
}
return result;
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,datetime :
function(index){
var result="";
var date_part="";
if($("#element_"+index+"_year").length==1){
date_part=$("#element_"+index+"_year-mm").val()+"/"+$("#element_"+index+"_year-dd").val()+"/"+$("#element_"+index+"_year").val();
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var time_part="";
if($("#element_"+index+"_hour").length==1){
time_part=$("#element_"+index+"_hour").val()+":"+$("#element_"+index+"_minute").val()+" "+$("#element_"+index+"_ampm").val();
}
if(date_part && time_part){
result=date_part+" "+time_part;
}else{
result=date_part ? date_part : time_part;
}
return result;
}
,url :
function(index){
return $("#element_"+index).val();
}
,file :
function(index){
return $("#element_"+index).val();
}
,Image :
function(index){
return $("#element_"+index).val();
}
,new_select_multiple :
function(index){
return $("#element_"+index).val();
}
,price :
function(index){
var result="";
var arr=new Array();
$("input[id^=element_"+index+"_]").each(function(){
arr[arr.length]=this.value;
});
result=arr.join(".");
return result;
}
,hidden :
function(index){
return $("#element_"+index).val();
}
,unique_id :
function(index){
return $("#element_"+index).val();
}
,section_break :
function(index){
return "";
}
,page_break :
function(index){
return "";
}
,signature :
function(index){
return $("#element_"+index).val();
}
,star_rating :
function(index){
var result="";
$("input[name=element_"+index+"]:checked").each(function(){
result=this.value;
});
return result;
}
,scale_rating :
function(index){
var result="";
$("input[name=element_"+index+"]:checked").each(function(){
result=this.value;
});
return result;
}
,deprecated :
function(index){
return $("#element_"+index).val();
}
,address :
function(index){
var result="";
var element_arr=$("input,select").filter("[name='element_"+index+"[]']").toArray();
result=element_arr[0].value+" "+element_arr[1].value+"\n"
+element_arr[2].value+","+element_arr[3].value+" "+element_arr[4].value+"\n"
+element_arr[5].value;
return result;
}
,name :
function(index){
var arr=new Array();
$("input[id^=element_"+index+"_]").each(function(){
arr[arr.length]=this.value;
});
var result=arr.join(" ");
return result;
}
,checkbox :
function(index){
var arr=new Array();
$("input[name='element_"+index+"[]']:checked").each(function(){
arr[arr.length]=this.value;
});
var result=arr.join(", ");
return result;
}
,select_multiple :
function(index){
return $("#element_"+index).val();
}
};
var emf_condition_id_to_js_map={5 :
function(field_value, value){
return field_value==value;
}
,6 :
function(field_value, value){
return field_value!=value;
}
,1 :
function(field_value, value){
return field_value.indexOf(value)>-1;
}
,2 :
function(field_value, value){
return field_value.indexOf(value)==-1;
}
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function(field_value, value){
return field_value.indexOf(value)==0;
}
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function(field_value, value){
return field_value.indexOf(value)==field_value.length-value.length;
}
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function(field_value, value){
return parseFloat(field_value)==parseFloat(value);
}
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function(field_value, value){
return parseFloat(field_value)>parseFloat(value);
}
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function(field_value, value){
return parseFloat(field_value) < parseFloat(value);
}
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function(field_value, value){
var date_for_field_value=Date.parse(field_value);
var date_for_value=Date.parse(value);
if(date_for_field_value && date_for_value){
return date_for_field_value == date_for_value;
}
return false;
}
,11 :
function(field_value, value){
var date_for_field_value=Date.parse(field_value);
var date_for_value=Date.parse(value);
if(date_for_field_value && date_for_value){
return date_for_field_value < date_for_value;
}
return false;
}
,12 :
function(field_value, value){
var date_for_field_value=Date.parse(field_value);
var date_for_value=Date.parse(value);
if(date_for_field_value && date_for_value){
return date_for_field_value > date_for_value;
}
return false;
}
};
var emf_group_to_field_rules_map=[];
var emf_group_to_page_rules_for_confirmation_map=[];
var emf_cart=null;
var emf_page_info={current_page_index: 0, page_element_index_min: 0, page_element_index_max: 63};
var emf_index_to_value_map=null;
var emf_form_visit_id="f2af8F0MAKf";
var emf_index_to_option_map=[];
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