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FORMULIR PESERTA DIDIK 2019

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


Jenis Kelamin : ..............................................................................................
NISN : ..............................................................................................
NIK : ..............................................................................................
Tempat Lahir : ..............................................................................................
Tanggal Lahir : ..............................................................................................
Agama : ..............................................................................................
Berkebutuhan Khusus : ..............................................................................................
Alamat Jalan : ..............................................................................................
RT/ RW : ..............................................................................................
Nama Dusun : ..............................................................................................
Desa/ Kelurahan : ..............................................................................................
Kecamatan : ..............................................................................................
Kode Pos : ..............................................................................................
Tempat Tinggal : ..............................................................................................
Moda Transportasi : ..............................................................................................
Nomor Telp : ..............................................................................................
Nomor HP : ..............................................................................................
Penerima KPS : ..............................................................................................
Ayah Kandung
Nama : ..............................................................................................
Tahun Lahir : ..............................................................................................
Pendidikan : ..............................................................................................
Pekerjaan : ..............................................................................................
Penghasilan : Kurang dari Rp. 500.000
Rp. 500.000 – Rp. 999.999
Rp. 1.000.000 – Rp. 1.999.999
Rp. 2.000.000 – Rp. 2.999.999
Berkebutuhan Khusus : ..............................................................................................
Ibu Kandung
Nama : ..............................................................................................
Tahun Lahir : ..............................................................................................
Pendidikan : ..............................................................................................
Pekerjaan : ..............................................................................................
Penghasilan : Kurang dari Rp. 500.000
Rp. 500.000 – Rp. 999.999
Rp. 1.000.000 – Rp. 1.999.999
Rp. 2.000.000 – Rp. 2.999.999

Wali
Nama : ..............................................................................................
Tahun Lahir : ..............................................................................................
Pendidikan : ..............................................................................................
Pekerjaan : ..............................................................................................
Penghasilan : Kurang dari Rp. 500.000
Rp. 500.000 – Rp. 999.999
Rp. 1.000.000 – Rp. 1.999.999
Rp. 2.000.000 – Rp. 2.999.999
Berkebutuhan Khusus : ..............................................................................................

Data Periodik
Tinggi Badan : ............... cm
Berat Badan : .............. kg
Jarak rumah ke sekolah : Kurang dari 1 km/ lebih dari 1 km
Sebutkan (dalam kilo meter) : ..............................................................................................
Waktu tempat ke sekolah : ............. jam/menit
Jumlah Saudara Kandung : ..............................................................................................

Bekasi, 20....
Orang Tua,

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