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STATUS KONSELING

1. IDENTITAS
Nama lengkap Siswa : ...............................................................................................................................
Nama Panggilan Siswa : ...............................................................................................................................
Kelas : ...............................................................................................................................
Tempat Tanggal Lahir : ...............................................................................................................................
Suku : ...............................................................................................................................
Agama : ...............................................................................................................................
Alamat : ...............................................................................................................................
Nama Orang Tua / Wali Siswa : ...............................................................................................................................
Pekerjaan Orang Tua / Wali : ...............................................................................................................................
Alamat Orang Tua / Wali : ...............................................................................................................................

Hari / Tanggal
Catatan Selama Observasi Keterangan
/ Jam

Catatan :
Dalam Keterangan diisi : - Datang Sendiri
- Dikirim
- Dipanggil

Luwuk,
Guru Bimbingan Konseling

MISBA M MASO, SPd


NIP. 19820204 200801 2 011

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