Buku Profil Siswa

BUKU PROFIL SISWA
PELAYANAN
BIMBINGAN KONSELING
NAMA
NIS
NISN
SMA NEGERI 5 PARIAMAN

2015
1
Di Isi Oleh Peserta Didik

IDENTITAS PESERTA DIDIK
1.
Nama
:..................................................................................
2.
Tempat/Tanggal Lahir
:..................................................................................
3.
Jenis Kelamin
:..................................................................................
4.
Agama
:..................................................................................
5.
Golongan Darah
6.
Tinggi/Berat Badan
7.
Anak Ke/Jumlah Bersaudara :..................................................................................
8.
Hobbi
:..................................................................................
9.
Alamat
:..................................................................................
10.
Nomor Telepon/ HP
:..................................................................................
11.
Diterima di Sekolah Ini
:..................................................................................
:..................................................................................
:..................................................................................
a.
Di Kelas
:..................................................................................
b.
Tanggal
:..................................................................................
c.
Semester
:..................................................................................
Sekolah Asal/Ijazah
:..................................................................................
12.
a. Nama sekolah Asal
:..................................................................................
b. Alamat
:..................................................................................
c. Nomor dan Tahun Ijazah
:..................................................................................
d. Jumlah SKHU
:..................................................................................
13.
Teman Dekat di Kelas
:..................................................................................
14.
Jurusan yang Diinginkan
:..................................................................................
15.
Hasil Tes Psikologis
:..................................................................................
16.
Cita-cita Sementara
:..................................................................................
17.
Rencana Setelah Tamat
: .................................................................................
18.
Nama Saudara :....................................................................................................

No
Nama
Umur
Pekerjaan/
Keterangan
Sekolah
1
2
3
4
5
6
7
8
9
10
19.
Anggota Keluarga Lain yang Tinggal di Rumah Anda

No
Nama
Umur
:
Pekerjaan/
Hubungan
Sekolah
Kelurga
1
2
3
4
5
6
7
8
9
10
BIODATA REKOMENDASI BIDIKMISI

...................................................................................................................
.
Nama siswa
...................................................................................................................
Jenis Kelamin ..................................................................................................................
Agama
...................................................................................................................
Tempat lahir ...................................................................................................................
NISN
Tanggal Lahir ...................................................................................................................

...................................................................................................................
Alamat
.
...................................................................................................................
Kab/Kota
.
Provinsi
...................................................................................................................
Email
...................................................................................................................
Kode Pos
...................................................................................................................
...................................................................................................................
No. Telepon
.
...................................................................................................................
No. Handphone
.
Foto Pribadi
*Klik gambar untuk memperbesar
Data Keluarga
Menampilkan form untuk mengisi/melengkapi data keluarga
Nama Ayah *
Status Ayah *
Masih Hidup
Wafat
Bercerai
Status Hubungan *
Pendidikan Ayah *
Kerja Ayah *
Detail Ayah *
Nama Ibu *
Status Ibu *
Masih Hidup
Wafat
Pendidikan Ibu *
Kerja Ibu *
Detail Ibu *
Jumlah Tanggungan *
Orang
Notelp Ortu
data kondisi rumah

Menampilkan form untuk mengisi/melengkapi data kondisi rumah siswa
Kepemilikan *
Kepemilikan harus diisi
Tahun Perolehan *
Tahun Perolehan harus diisi
Sumber Listrik *
Sumber Listrik harus diisi
Daya Listrik *
Hanya diisi jika sumber listrik PLN
Luas Tanah *
Luas Tanah harus diisi
NJOP/Meter *
NJOP/Meter harus diisi
Luas Bangunan *
Luas Bangunan harus diisi
Bahan Atap *
Bahan Atap harus diisi
Bahan Lantai *
Bahan Lantai harus diisi
Bahan Tembok *
Bahan Tembok harus diisi
Mandi Cuci Kakus *
Kepemilikan Sendiri Didalam

Kepemilikan Sendiri Diluar
Berbagi Pakai
Mandi Cuci Kakus harus diisi
Sumber Air Utama *
Kemasan
PDAM
Sumur
Sungai/Mata air
Sumber Air Utama harus diisi
Jarak dari pusat kota *
Km
Jarak dari pusat kota harus diisi
Jumlah orang tinggal *
orang
Jumlah orang tinggal harus diisi
Data Kondisi Ekonomi Orang Tua

Menampilkan form untuk mengisi/melengkapi data kondisi ekonomi orang tua
Kondisi Ekonomi Orang tua
Penghasilan Ayah *
Penghasilan Ibu *
Total Hutang Kepada Pihak Lain
Rp.
0
Cicilan Hutang Dibayar Per Bulan

Rp.
Total Piutang Kepada Pihak Lain
Rp.
Cicilan Piutang Dibayar Per Bulan
Rp.
Tabungan Keluarga
Rp.
Siswa pemegang kartu perlindungan sosial (KPS) / bantuan siswa miskin (BSM)
Keterangan
Penghasilan Ayah
Pilih kotak yang sesuai dengan rata rata penghasilan kotor per bulan yang diterima oleh Ayah / Wali dalam
4 bulan terakhir. Contoh : pilih kotak < 1 Juta jika penghasilan kotor 4 bulan terakhir adalah 1. Bulan 1 :
Rp500.000,- 2. Bulan 2 : Rp300.000,- 3. Bulan 3 : Rp400.000,- 4. Bulan 4 : Rp400.000.- 5. Rata-rata :
Rp400.000.-
Penghasilan Ibu
Pilih kotak yang sesuai dengan rata rata penghasilan kotor per bulan yang diterima oleh Ibu dalam 4 bulan
terakhir. Contoh : pilih kotak < 1 Juta jika penghasilan kotor 4 bulan terakhir adalah 1. Bulan 1 :
Rp500.000,- 2. Bulan 2 : Rp300.000,- 3. Bulan 3 : Rp400.000,- 4. Bulan 4 : Rp400.000.- 5. Rata-rata :
Rp400.000.-
Contoh kartu perlindungan sosial(KPS)
Data Rencana Hidup/Tinggal

Menampilkan form untuk mengisi/melengkapi data rencana hidup/tinggal pendaftar di
perguruan tinggi tujuan
Rencana Tinggal *
Bersama Keluarga / Kenalan

Kos/Sewa
Pesantren
Belum Ada
Dukungan Keluarga *
Ya
Tidak
Transportasi Asal *
Pesawat Terbang
Kapal Laut
Jalur Darat
Transportasi Harian *
Sepeda Motor
Sepeda
Becak
Kendaraan Umum
Lain-lain
Biaya Transportasi *
Rp.
,-
20.
Riwayat Pendidikan :
No
1
2
3
4
5
6
21.
Nama Satuan Pendidikan
Tahun
Tempat
Hasil Belajar pada Pendidikan Sebelumnya :

a. Sekolah Dasar :
No
1
2
3
4
5
6
7
8
9
Mata
Pelajaran
Pendidikan Agama
Kewarganegaraan
Bahasa Indonesia
Matematika
Ilmu Pengetahuan Alam
Ilmu Pengetahuan Sosial
Kesenian
Pendidikan Jasmani
Muatan Lokal
a.
b.
c.
Jumlah
Rata-rata
b. Sekolah Lanjutan Tingkat Pertama (SMP/MTs)

No
1
2
3
4
5
Nilai
Tertulis
Mata
Pelajaran
Pendidikan Agama
Kewarganegaraan
Bahasa Indonesia
Matematika
Ilmu Pengetahuan Alam
Praktek
Nilai
Tertulis
Praktek
10
6
7
8
9
10
11
22.
Ilmu Pengetahuan Sosial

Kesenian
Pendidikan Jasmani
Muatan Lokal
Pilihan
a. Keterampilan
b. Teknologi Informasi dan
Komunikasi
Muatan Lokal
a.
b.
Jumlah
Rata-rata
Isilah daftar pernyataan di bawah ini dengan lengkap dan akurat
a.
Apakah sekolah ini sesuai dengan pilihan Anda ?....................................................
b.
Apa faktor penunjang keberhasilan Anda ? Jelaskan
c.
Apa faktor penghambat yang menjadi gangguan proses belajar Anda ?...................
d.
Jarak tempat tinggal ke sekolah ?.................................. KM
e.
Trasfortasi anda ke sekolah ?
f.
Bagaimana keadaan tempat belajar Anda ?...
g.
Siapa yang sering membantu Anda belajar di rumah ?..............................................
h.
Kapan Saja waktu belajar Anda di rumah ?..............................................................
i.
Bagaimana peranan orang tua untuk menunjang keberhasilan Anda ?.....................
j.
Sekarang Anda tinggal dengan siapa ?.....................................................................
k.
Jika mengalami kesulitan/masalah Anda membicarakan kepada.
l.
Sebutkan jenis yang sering Anda lakukan di luar sekolah ?......................................
11
m.
Penyakit apa yang pernah Anda derita ?....................................................................

23.
a.
b.
c.
Identitas Orang Tua/Wali
Ayah Kandung
- Nama Lengkap/Panggilan
:..
- Umur
:..
- Pendidikan Terakhir
:..
- Pekerjaan/Spesifik Pekerjaan
:..
- Penghasilan/bulan
:..
- Alamat
:..
- Nomor Telepon/HP
:..
Ibu Kandung
:..
- Umur
:..
:..
:..
- Penghasilan/bulan
:..
- Alamat
:..
- Nomor Telepon/HP
:..
:..
- Umur
:..
:..
:..
- Penghasilan/bulan
:..
- Alamat
:..
- Nomor Telepon/HP
:..
Wali
12
d.
Pas Photo 3x4
Pariaman .. 20..
Peserta didik Ybs,
13
Di isi Oleh Konselor

KEHADIRAN PESERTA DIDIK
N
O
BULAN
1
2
3
Juli
Agustus
Septembe
4
5
6
7
8
9
10
11
12
r
Oktober
November
Desember
Januari
Februari
Maret
April
Mei
Juni
KELAS X
I
A T
KEHADIRAN
KELAS XI
S I
A T C
KELAS XII
I
A T C
LAPORAN KASUS SISWA

KELAS
:X
NO
HARI/
TANGGAL
KASUS
NOMOR
BOBOT
PONIT
14
1
2
3
4
5
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
Pariaman20
Konselor
..
NIP.
LAPORAN KASUS SISWA
KELAS
: XI
NO
HARI/
TANGGAL
KASUS
NOMOR
BOBOT
PONIT
15
1
2
3
4
5
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
Pariaman20
Konselor
..
NIP.
LAPORAN KASUS SISWA
KELAS
: XII
NO
HARI/
TANGGAL
KASUS
NOMOR
BOBOT
PONIT
16
1
2
3
4
5
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
Pariaman20
Konselor
..
NIP.
SURAT PERJANJIAN PESERTA DIDIK
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32
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PERKEMBANGAN HASIL BELAJAR PESERTA DIDIK

N
O
MATA
PELAJARAN
KELAS X
SMT I
SMT 2
K
KELAS XI
SMT I
SMT 2
K
KELAS XII
SMT 1 SMT 2
K
Pendidikan
agama
33
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
Kewarganegaraan
Bahasa dan
Sastra Indonesia
Bahasa Inggris
Matematika
Kesenian
Penjaskes
Sejarah
Geografi
Ekonomi
Sosiologi
Fisika
Kimia
Biologi
TIK
Mulok
Bahasa Jerman
Jumlah
Rata-rata
Jlh MP Tuntas
Jlh MP tidak Tuntas
Pariaman20
Konselor
..
NIP.
Pengembangan Diri
N
Jenis Kegiatan
II
III
IV
VI
o
1
2
34
3
4
5
6
Akhlak Mulia dan Kepribadian

N
o
1
2
3
4
5
6
7
8
9
10
Aspek yang Dinilai
II
III
IV
VI
II
III
IV
VI
Kedisiplinan
Kebersihan
Kesehatan
Tanggung Jawab
Sopan Santun
Percaya Diri
Kompetitif
Hubungan Sosial
Kejujuran
Pelaksanaan Ibadah Ritual
Ketidakhadiran
N
Alasan Ketidakhadiran
o
1
2
3
INVENTORI BAKAT
N
o
Akademik
(Umum)
Non Akademik
(Khusus)
35
PEDOMAN OBSERVASI
Pengamat :
Kelas
Aspek
yang Dinilai
Hasil
Pengamatan
Keterangan
36
XI
XII
ANGKET PENYAKIT YANG PERNAH DIDERITA

N
o
Penyakit yang Pernah

Diderita/Sedang Dialami
Usaha yang
Telah Dilakukan
Kondisi
Sekarang
37
KARTU KONSELING INDIVIDUAL/KONSULTASI

Hari/
tangga
l
masalah
Deskripsi Masalah dan Pengentasan
Keterangan
38

Hari/
tangga
l
masalah
Keterangan
39

Hari/
tangga
l
masalah
Keterangan
40

Hari/
tangga
l
masalah
Keterangan
41
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53

Buku Profil Siswa

Diunggah oleh

Informasi Dokumen

Judul Asli

Hak Cipta

Format Tersedia

Bagikan dokumen Ini

Bagikan atau Tanam Dokumen

Opsi Berbagi

Apakah menurut Anda dokumen ini bermanfaat?

Apakah konten ini tidak pantas?

Hak Cipta:

Format Tersedia

Buku Profil Siswa

Diunggah oleh

Hak Cipta:

Format Tersedia

BUKU PROFIL SISWA

SMA NEGERI 5 PARIAMAN

Di Isi Oleh Peserta Didik

Anak Ke/Jumlah Bersaudara :..................................................................................

Diterima di Sekolah Ini

a. Nama sekolah Asal

c. Nomor dan Tahun Ijazah

Teman Dekat di Kelas

Jurusan yang Diinginkan

Hasil Tes Psikologis

Rencana Setelah Tamat

Nama Saudara :....................................................................................................

Anggota Keluarga Lain yang Tinggal di Rumah Anda

BIODATA REKOMENDASI BIDIKMISI

Tanggal Lahir ...................................................................................................................

*Klik gambar untuk memperbesar

data kondisi rumah

Kepemilikan Sendiri Didalam

Data Kondisi Ekonomi Orang Tua

Cicilan Hutang Dibayar Per Bulan

Contoh kartu perlindungan sosial(KPS)

Data Rencana Hidup/Tinggal

Bersama Keluarga / Kenalan

Nama Satuan Pendidikan

Hasil Belajar pada Pendidikan Sebelumnya :

b. Sekolah Lanjutan Tingkat Pertama (SMP/MTs)

Ilmu Pengetahuan Sosial

Isilah daftar pernyataan di bawah ini dengan lengkap dan akurat

Apakah sekolah ini sesuai dengan pilihan Anda ?....................................................

Apa faktor penunjang keberhasilan Anda ? Jelaskan

Jarak tempat tinggal ke sekolah ?.................................. KM

Trasfortasi anda ke sekolah ?

Bagaimana keadaan tempat belajar Anda ?...

Siapa yang sering membantu Anda belajar di rumah ?..............................................

Kapan Saja waktu belajar Anda di rumah ?..............................................................

Bagaimana peranan orang tua untuk menunjang keberhasilan Anda ?.....................

Sekarang Anda tinggal dengan siapa ?.....................................................................

Jika mengalami kesulitan/masalah Anda membicarakan kepada.

Sebutkan jenis yang sering Anda lakukan di luar sekolah ?......................................

Penyakit apa yang pernah Anda derita ?....................................................................

Identitas Orang Tua/Wali

Pas Photo 3x4

Di isi Oleh Konselor

LAPORAN KASUS SISWA

SURAT PERJANJIAN PESERTA DIDIK

SURAT PERJANJIAN PESERTA DIDIK

SURAT PERJANJIAN PESERTA DIDIK

SURAT PERJANJIAN PESERTA DIDIK

SURAT PERJANJIAN PESERTA DIDIK

SURAT PERJANJIAN PESERTA DIDIK

SURAT PERJANJIAN PESERTA DIDIK

SURAT PERJANJIAN PESERTA DIDIK

SURAT PERJANJIAN PESERTA DIDIK

SURAT PERJANJIAN PESERTA DIDIK

SURAT PERJANJIAN PESERTA DIDIK

SURAT PERJANJIAN PESERTA DIDIK

SURAT PERJANJIAN PESERTA DIDIK

SURAT PERJANJIAN PESERTA DIDIK

SURAT PERJANJIAN PESERTA DIDIK

PERKEMBANGAN HASIL BELAJAR PESERTA DIDIK

Akhlak Mulia dan Kepribadian

Aspek yang Dinilai

ANGKET PENYAKIT YANG PERNAH DIDERITA