Директору Іршавської районної станції юних техніків

БОЙКО  ВАСИЛЮ  ВАСИЛЬОВИЧУ

                                 Учень________класу,  курсу, школи, СПТУ____________________________________________

                                        с._______________________________________________________________________________

                                                           ( прізвище, ім’я, по батькові)                                                                                             

                                            Домашня адреса:_________________________________________________________________                                                           ( вулиця, номер будинку, квартира)                                                                                                                                                                                              Тел._________________________________                                                                                                                                                                                                                                            

З  А  Я  В  А

                                                                                                                                                                                                                           Прошу зарахувати мене в гурток________________________________________________________________________________

                ____________________________________________________________________________________________________________

                ____________________________________________________________________________________________________________

                                                                                                                             ( назва гуртка )

                ________               ______________________________________року  навчання.                                                                                                                                      ( першого, другого)                                                                                                                                          

                „_____”___________________________2012   року                    ____________________________________________________                                                                                                                                                                                                                                                                                                                                                                                                                                           ( підпис )

                Заняття в гуртку  погоджено з батьками, класним керівником  або вихователем______________________________________

                ___________________________________________________________________________________________________________

                                                               ( прізвище, ім’я , по батькові, місце роботи і посада   батьків )                        

                ___________________________________________________________________________________________________________

                                                                                                                             _____________________________________________

                                                                                                                                                        ( підпис одного з батьків )

                ____________________________________________________________________________________________________________                                                                     ( прізвище, ім’я по батькові класного керівника, вихователя )                          

                                                                                                                             _____________________________________________                                                                                                                                    ( підпис кл. керівника, вихователя )   

                Пропозиції керівника гуртків_________________________________________________________________________________

_______________________________________________________________________________________________________

                ___________________________________________________________________________________________________________

                                               ( пропозиції щодо зарахування або причини відмови )