ADMINISTRASI KESISWAAN

FORMULIR PENDAFTARAN SISWA BARU

TAHUN PELAJARAN ………………

A.             KETERANGAN MURID

1.     Nama Lengkap                              :  ................................................................................................

2.    Nama Panggilan                             :  ................................................................................................

3.    Jenis Kelamin                                :  ................................................................................................

4.    Tempat/Tanggal Lahir                   :  ................................................................................................

5.    A g a m a                                       :  ................................................................................................

6.    Kewarganegaraan                          :  WNI/WNA Keturunan

7.    Anak Ke                                        :  ……………………… (dari satu ibu)

8.    Jumlah Saudara Kandung              :  .......................................................................................

9.    Jumlah Saudara Tiri                      :  ................................................................................................

10.  Jumlah Saudara Angkat                 :  ................................................................................................

11.  Bahasa Sehari-hari                        :  ................................................................................................

12.  Berat Badan                                   :  ……………………………….. kg

13.  Tinggi Badan                                 :  ……………………………….. cm

14.  Golongan Darah                            :  ................................................................................................

15.   Penyakit Berat yang Pernah Diderita  :  ..........................................................................................

16.     Alamat Tempat Tinggal                 :  ................................................................................................

           Nomor Telepon                            :  ................................................................................................

17.        Bertempat Tinggal Pada                 :  ……………………… . (Orangtua/Menumpang/Asrama)

B.              ORANGTUA/WALI

18.          Nama

          -  Ayah Kandung                   :  ................................................................................................

          -  Ibu Kandung                      :  ................................................................................................

19.          Pendidikan Tertinggi

                                              -  Ayah Kandung                    :  ..................................................................................................

                                              -  Ibu Kandung                       :  .................................................................................................

20.          Pekerjaan                                    

          -  Ayah                                   :  ................................................................................................

          -  Ibu                                      :  ................................................................................................

21.          Nama Wali Murid                         :  ..............................................................................................

22.          Pendidikan Tertinggi                    :  ..............................................................................................

23.          Hubungan Terhadap Anak           :  ...............................................................................................

24.          Pekerjaan                                     :  ................................................................................................

C.             ASAL MULA ANAK

25.          Masuk Madrasah ini sebagai        :  Murid Baru Kelas I/

                                                                                           :  Pindahan *(Teruskan No. 27)

26    a. Asal anak                                 :  Rumah Tangga/TK (teruskan No. 28)

        b.  Nama Taman Kanak-kanak  :..............................................................…………...........................

        c. Nomor/tahun surat keterangan:  ……………………………………………………………

d. Lama Belajar (Lanjutkan No. 28)................................................................ :  ………………… tahun

27.      Pindahan dari  :

        a. Nama Madrasah Asal                 :  ……………………………….................................................

           b. Tanggal                                    :  ……………………………………………………………….

           c. Dari Kelas                                :  ……………………………………………………………….

28.      Diterima di madrasah ini             

           a. Tanggal                                    :  ……………………………………………………………….

           b. Di Kelas                                   :  ……………………………………………………………….

                                                                                                              ……………………………….

                                                                                                                                          Orang tua/Wali*)

                                                                                                                                         

                                                                                                                                          Nama Lengkap

Diterima/ditolak*)

Alasan ……………………………….

                ………………………………

Kepala Sekolah

MAMAN MUNAWAR, S.Pd.....

NIP. 19770310 199903 1 005

CATATAN :*) Coret yang tidak perlu