PENDIDIKAN ANAK USIA DINI

ASY-SYFA AZ-ZAHRA
KOTA PONTIANAK BARAT KECAMATAN SUI. JAWI LUAR
Alamat: Jalan. Kom Yos Sudarso Gg. Timun 1 Jalur H. Tasib

‫بسم هللا الرحمن الرحيم‬

FORMULIR PENDAFTARAN
CALON PESERTA DIDIK BARU PAUD ISLAMI
TAHUN PELAJARAN 2020/2021

I. DATA CALON PESERTA DIDIK :

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

Nama Panggilan : ..........................................................................................................
Jenis Kelamin : Laki – laki / Perempuan*
Tempat & Tgl Lahir : ..........................................................................................................
Agama : ..........................................................................................................
Anak -ke : ........................dari..............................saudara…..............................
Golongan Darah : ..........................................................................................................
Kelainan Pada Anak : ..........................................................................................................
Sifat yang Menonjol : ..........................................................................................................

Bahasa Ibu ( Sehari2) : ..........................................................................................................

Asal Play Group : ..........................................................................................................
Alamat Rumah : ..........................................................................................................

II. DATA ORANG TUA/ WALI CALON PESERTA DIDIK :

Nama Ayah / Wali* : ..........................................................................................................
Tempat & Tgl Lahir : ..........................................................................................................
Agama : ..........................................................................................................
Pendidikan Terakhir : ..........................................................................................................
Pekerjaan : ..........................................................................................................
Alamat : ..........................................................................................................

Penghasilan Perbulan : ..........................................................................................................

Telp. Rumah : ………………………….. / HP : ………………………………….

Nama Ibu / Wali* : ..........................................................................................................

Tempat & Tgl Lahir : ..........................................................................................................
Agama : ..........................................................................................................
Pendidikan Terakhir : ..........................................................................................................
Pekerjaan : ..........................................................................................................
Alamat : ..........................................................................................................
Penghasilan Perbulan : ..........................................................................................................
Telp. Rumah : ………………………….. / HP : ………………………………….

Keterangan Lain Calon Peserta Didik :

Berat Badan : .................... Kg.
Tinggi Badan : .................... Cm.
Ukuran Baju : S / M/ L/ XL/ XXL/ Jumbo
Pontianak, .............................2020
Orang Tua/ Wali Calon Peserta Didik