FORMAT S-1

Nomor
Pendaftaran

NAMA SEKOLAH
STATUS SEKOLAH
ALAMAT
DESA/KELURAHAN
KECAMATAN
KODYA/DATI II
PROVINSI/DATI I

: SD SANTO YOSEPH 2
: SWASTA
: JALAN SERMA KAWI NO.2
: DAUH PURI KELOD
: DENPASAR BARAT
: DENPASAR
: BALI

NDS : 22.090013

FORMULIR PENDAFTARAN SISWA BARU

TAHUN PELAJARAN 2009/2010
A.KETERANGAN SISWA
1. Nama Lengkap
2. Nama Panggilan
3. Jenis Kelamin
4. Tempat dan tanggal lahir
5. Agama
6. Kewarganegaraan: WNI/WNA keturunan *)
7. Anak nomor ke
8. Jumlah saudara kandung
9. Jumlah saudara tiri
10. Banyak saudara angkat
11. Bahasa sehari-hari
12. Berat badan
13. Tinggi badan
14. Golongan darah
15 .Penyakit yang pernah diderita
16. Alamat tempat tinggal
No.Telepon
17. Bertempat tinggal pada

: .............................................................................................................
:..............................................................................................................
:..............................................................................................................
:..............................................................................................................
:..............................................................................................................
:..............................................................................................................
:...............................................................................................................
:..............................................................................................................
:...............................................................................................................
:..............................................................................................................
:..............................................................................................................
:..............................................................................................................
:..............................................................................................................
:..............................................................................................................
:..............................................................................................................
:..............................................................................................................
:..............................................................................................................
: Orang tua/menumpang/asrama *)

B. ORANG TUA/WALI
18. Nama Ayah kandung
Nama Ibu kandung
19. Pendidikan tertinggi Ayah kandung
Pendidikan tertinggi Ibu Kandung
20. Pekerjaan Ayah
Pekerjaan Ibu
21. Nama wali siswa (jika ada)
22. Pendidikan tertinggi
23. Hubungan terhadap anak
24. Pekerjaan

:..............................................................................................................
:..............................................................................................................
:..............................................................................................................
:..............................................................................................................
: PNS/ABRI/Pegawai Swasta/Wiraswasta/Petani/Nelayan *)
: PNS/ABRI/Pegawai Swasta/Wiraswasta/Petani/Nelayan *)
:..............................................................................................................
:..............................................................................................................
:..............................................................................................................
: PNS/ABRI/Pegawai Swasta/Wiraswasta/Petani/Nelayan *)

C.ASAL MULA SISWA

25. Masuk sekolah ini sebagai
: Murid baru Tk.1/pindahan *) (jika pindahan teruskan ke no.27)
26. a.Asal siswa:
b.Nama Taman kanak-kanak
:.............................................di.............................................................
c. Tahun dan No.STTB/Surat Keterangan
:.............................................di.............................................................
d. Lama belajar
:..............................................................................................................
27. Pindahan dari:
a. Nama sekolah asal
:...............................................................................................................
b. Tanggal
:..............................................................................................................
c. Dari kelas
:..............................................................................................................
28. Diterima di sekolah ini:
a. Tanggal
:.
b. Di kelas
:...
Diterima./ ditolak *)
Alasan : ..

Denpasar, ..2009
Orang tua/wali murid

Kepala Sekolah,

Dra.Luh Putu Udayati, M.Pd

Catatan:
*) coret yang tidak perlu