KETERANGAN TENTANG DIRI PESERTA DIDIK

1. Nama S Peserta Didik (Lengkap) : ____________________________________________________

2. Nomor Induk : ____________________________________________________
3. Tempat, Tanggal Lahir : ____________________________________________________
4. Jenis Kelamin : ____________________________________________________
5. Agama : ____________________________________________________
6. Status dalam Keluarga : ____________________________________________________
7. Anak ke : ____________________________________________________
8. Alamat Peserta Didik :____________________________________________________

____________________________________________________
Telepon : ____________________________________________________
9. Sekolah Asal : ____________________________________________________
10. Diterima disekolah ini
di kelas : ____________________________________________________
pada tanggal : ____________________________________________________
11. Nama Orang Tua : ____________________________________________________
a. Ayah : ____________________________________________________
b. Ibu : ____________________________________________________
12. Alamat Orang Tua : ____________________________________________________
: ____________________________________________________
Telepon/HP : ____________________________________________________
13. Pekerjaan Orang Tua
a. Ayah : ____________________________________________________
b. Ibu : ____________________________________________________
14. Nama Wali : ____________________________________________________
15 Alamat Wali : ____________________________________________________

: ____________________________________________________

Telepon : ____________________________________________________

16. Pekerjaan Wali : ____________________________________________________

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Kepala Sekolah

Pasfoto

3x4
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NIP.