BORANG 001PK

BORANG PENDAFTARAN MURID PENDIDIKAN KHAS

BERMASALAH PEMBELAJARAN

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A. MAKLUMAT MURID
Nama : .........................................................................................................

Jantina : .......................................................................

Tarikh Lahir : ........................................................................................

Tempat : ......................................................................

No.Surat Lahir/Sijil Sumpah : .........................................................................................................................................................

Agama : ......................................................................................................

Keturunan : ..............................................................

Kenderaan ke sekolah : ........................................................................................................................................................................

Kelas : ...............................................................................................................................................................................................................
.

B. BUTIR-BUTIR KELUARGA
Nama Bapa/Penjaga :
.............................................................................................................................................................................

No.Kad Pengenalan Bapa/Penjaga : ............................................................................................................................................

Pekerjaan : ............................................................................................

Warganegara : ..............................................................

Nama Ibu : .............................................................................................

Pekerjaan : .....................................................................

No.Kad Pengenalan Ibu : ....................................................................................................................................................................

Pekerjaan : ............................................................................................. Warganegara : .............................................................
Bahasa Pertuturan : ................................................................................................................................................................................
Murid ......................................................................................................... anak ke ............................................ dalam keluarga
Ramai anak dalam keluarga .......................................... orang.
Tahun Dilahirkan Setiap Anak : 1. ...................... 2. ...................... 3. ...................... 4. ...................... 5. ......................
6. ...................... 7. ...................... 8. ...................... 9. ...................... 10. ......................
Alamat Tempat Tinggal : ....................................................................................................................................................................
.................................................................................................................................................................................................................................

Alamat Surat Menyurat : ....................................................................................................................................................................

.................................................................................................................................................................................................................................

No.Telefon Tempat Bekerja Bapa :...............................................................................................................................................

No.Telefon Rumah :.................................................................................................................................................................................

SURAT PERJANJIAN MENGIKUTI PROGRAM

PENDIDIKAN KHAS INTEGRASI ( MASALAH PEMBELAJARAN )
SEKOLAH PUSAT SEKOLAH KEBANGSAAN BUM BUM, SEMPORNA.
Mengikut Akta Pendidikan 1996 yang disebutkan di bawah (Peraturan-peraturan
Pendidikan Khas) 1997 dalam bahagian II dinyatakan:
3.(1) Bagi sekolah kerajaan dan bantuan kerajaan, murid-murid dengan
keperluan khas adalah layak .untuk menghadiri program Pendidikan Khas
KECUALI bagi murid berikut :
Murid cacat anggota tetapi mempunyai kebolehan mental untuk belajar
seperti murid biasa. Murid yang mempunyai pelbagai kecacatan atau sangat
cacat anggotanya atas terencat akal berat.
(2)

Seorang murid dengan keperluan khas adalah boleh dididik jika dia mampu
untuk mengurus diri sendiri tanpa bergantung kepada bantuan
orang lain dan disahkan oleh sesuatu panel yang terdiri daripada pengamal
perubatan, pegawai dari Kementerian Pendidikan dan pegawai dari Jabatan
Kebajikan Masyarakat mengikuti program pendidikan kebangsaan.
Saya.......................................
..............

Ibubapa/Penjaga

kepada..............................................................................................................
....... telah membaca dan memahami kandungan akta pendidikan 1996 yang
tersebut di atas. Dengan ini saya bersetuju menerima tawaran memasuki
program

pendidikan

dengan

tempoh

percubaan

selama

bulan

bertarikh.hingga
......sekiranya dalam tempoh tersebut anak saya
didapati tidak dapat memenuhi peraturan yang telah ditetapkan, saya
bersetuju untuk merujuk permohonan saya ke pejabat Kebajikan Am
Masyarakat berhampiran untuk mendapatkan penempatan yang bersesuaian
dengan anak jagaan saya.
Sekian, Terima Kasih.
Nama

..............................................

...............................
Tarikh : .........

Tandatangan

Nama

Guru

...............

Tandatangan

...............................
Tarikh : .........
Disahkan oleh :
Nama

................

Tandatangan

...............................
Jawatan : .........

BIODATA MURID
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Nama

........................................................................................................................................

No.Surat Beranak/Kad Pengenalan

........................................................................................................................................

Tarikh Lahir

........................................................................................................................................

Jenis kecacatan/Kategori :
........................................................................................................................................

No.Kad OKU

No.Akaun BSN

........................................................................................................................................

........................................................................................................................................

Jantina

Warganegara

........................................................................................................................................

........................................................................................................................................

Tempat Lahir

Tarikh Masuk sekolah

........................................................................................................................................

........................................................................................................................................

No.Daftar Sekolah

Nama Sekolah Asal

........................................................................................................................................

........................................................................................................................................

Agama

........................................................................................................................................

Bangsa

........................................................................................................................................

Nama Bapa/Penjaga

........................................................................................................................................

No.Kad pengenalan Bapa :

........................................................................................................................................

Pekerjaan Bapa/Penjaga

Nama Ibu/Penjaga

........................................................................................................................................

........................................................................................................................................

No.Kad Pengenalan Ibu/Penjaga

........................................................................................................................................

Pekerjaan Ibu/Penjaga

........................................................................................................................................

Alamat Tempat Tinggal

........................................................................................................................................
...........................................................................................................
.............................
...........................................................................................................
.............................

No.Telefon

........................................................................................................................................

Nama Kelas/Tahun

Nama Guru Kelas

........................................................................................................................................

........................................................................................................................................