Format : S-1

Nomor Statistik Sekolah

Nomor Pendaftaran

NAMA SEKOLAH

: MI CIOKONG

STATUS SEKOLAH

: TERAKREDITASI

ALAMAT SEKOLAH : CIOKONG
DESA/KELURAHAN

: SUKA RESIK

KECAMATAN

: SIDAMULIH

KABUPATEN

: CIAMIS

PROVINSI

: JAWA BARAT

FORMULIR PENDAFTARAN SISWA BARU
Tahun Pelajaran ........................../...........................
Keterangan Siswa
Nama Lengkap

: .....................................................................................

Nama Panggilan

: .....................................................................................

Jenis Kelamin
Tempat Tanggal Lahir

: .....................................................................................
: .....................................................................................
.....................................................................................
.....................................................................................

Agama
Kewarganegaraan

: .....................................................................................
: WNI/WNA Keturunan *)
.....................................................................................

Anak Nomor Ke

: ..............................................................(Dari satu Ibu)

Jumlah Saudara Kandung

: .....................................................................................

Jumlah Saudara Tiri

: .....................................................................................

Jumlah Saudara Anggkat

: .....................................................................................

Bahasa Sehari-hari

: .....................................................................................

Berat Badan

: ........................................................................... Kg

Tinggi Badan

: ............................................................................ Cm

Golongan Darah

: .....................................................................................

Penyakit yang pernah diderita

: .....................................................................................

Alamat Tempat Tinggal

: .....................................................................................
.....................................................................................
No. Tlp. ........................................................................

Bertempat Tinggal Pada

: Orang Tua/Menumpang/Asrama/Wali *)

Catatan :
*) Coret yang tidak perlu
Orang Tua Wali
Nama Ayah Kandung

: ....................................................................................

Nama Ibu Kandung

: ....................................................................................

Pendidikan Terakhir
Ayah kandung

: ....................................................................................

Ibu Kandung

: ....................................................................................

Pekerjaan Orang Tua
Ayah kandung

: PNS/ABRI/Peg. Swasta/Wiraswasta/Petani/Nelayan/
Sopir/ Ibu Rumah Tangga *)

Ibu Kandung

: PNS/ABRI/Peg. Swasta/Wiraswasta/Petani/Nelayan/
Sopir/ Ibu Rumah Tangga *)

Nama Wali Siswa

: ....................................................................................

Pendidikan Terakhir Wali

: ....................................................................................

Hubungan Terhadap Anak

: ....................................................................................

Pekerjaan Wali

: PNS/ABRI/Peg. Swasta/Wiraswasta/Petani/Nelayan/
Sopir/ Ibu Rumah Tangga *)

Asal Muasal Anak
Masuk sekolah ini sebagai

: ....................................................................................

Asal Anak
Asal Anak

: ....................................................................................

Nama Taman Kanak-kanak

: ....................................................................................

Nomor/ Tahun Surat Keterangan : ....................................................................................
Lama Belajar (Lanjutan No 28) : ....................................................................................
Pindahan Dari
Nama Sekolah Asal

: ....................................................................................

Tanggal

: ....................................................................................

Dari Kelas

: ....................................................................................

Diterima si sekolah ini
Tanggal

: ....................................................................................

Di kelas

: ....................................................................................

Diterima / Ditolak *)
Alasan ...............................................................................................................................................

Kepala Sekolah,

____________________________
NIP.

Ciokong, ....................................................
Orang Tua/Wali

__________________________________

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