PEMERINTAH KOTA KEDIRI

DINAS PENDIDIKAN
SEKOLAH MENENGAH PERTAMA NEGERI 8
E-mail : smpnegeri8kediri@gmail.com
NPSN : 20534366, NSS : 102105630105
Jl. Penanggungan No. 2 Telp. (0354) 771760. Kopos 64114 KEDIRI

DATA SISWA KELAS VII SMP NEGERI 8

TAHUN PELAJARAN 20 / 20_____ KELAS

A KETERANGAN TENTANG DIRI SISWA ………..

1. Nama siswa .
:..........................................................................................
a. Nama Lengkap :..........................................................................................
b. Nama Panggilan :..........................................................................................
2. Jenis Kelamin :..........................................................................................
3. Tempat / Tanggal lahir :..........................................................................................
4. Agama :.........................................................................................
5. Kewarganegaraan :.........................................................................................
6. Anak ke- :.........................................................................................
7. Jumlah saudara
a. kandung :........................................................................................
b. tiri :........................................................................................
c. angkat : ………………………………………............................
8. Golongan darah ..........................................................................................
9. Anak yatim / piatu / yatim piatu :........................................................................................
10. Bahasa sehari-hari dirumah :........................................................................................

B. KETERANGAN TEMPAT TINGGAL

11. Alamat :......................................................................................

........................................................................................
12. Nomor Telepon/ Handphone :......................................................................................
13. Tinggal dengan orang tua/saudara:......................................................................................
Di rumah sendiri/asrama/kost :......................................................................................
14. Jarak tempat tinggal ke sekolah :.....................................................................................

C. KETERANGAN KESEHATAN
15. Penyakit yang pernah diderita
TBC / Cacar / Malaria dll :......................................................................................
16. Kelainan jasmani :......................................................................................
17. Tinggi dan berat badan :......................................................................................

D. KETERANGAN PENDIDIKAN

18. Pendidikan sebelumnya

a. Lulus dari : SD/MI..........................................................................
b. Tanggal dan nomor ijazah :......................................................................................
c. Tanggal dan nomor SKHU :......................................................................................
d. Lama belajar :.....................................................................................
19. Pindahan
a. Dari sekolah :....................................................................................
b. Alasan :.....................................................................................
20. Diterima disekolah ini pada
a. Di Tingkat :....................................................................................
b. Tanggal :.....................................................................................
E. KETERANGAN TENTANG AYAH KANDUNG

22. Nama :.......................................................................................

23. Tempat dan tanggal lahir :.......................................................................................
24. Agama :......................................................................................
25. Kewarganegaraan :......................................................................................
26. Pendidikan :......................................................................................
27. Pekerjaan :.......................................................................................
28. Penghasilan per bulan :.......................................................................................
29. Alamat rumah :.......................................................................................
30. Nomor Telepon/( Hp ) :.......................................................................................

31. Masih Hidup / meninggal :......................................................................................

F. KETERANGAN TENTANG IBU KANDUNG

32. Nama :.....................................................................................

33. Tempat dan tanggal lahir
34. Agama
35. Kewarganegaraan
36. Pendidikan
37. Pekerjaan
38. Penghasilan per bulan
39. Alamat rumah
40. Nomor Telepon/
41. Masih Hidup / meninggal
:.....................................................................................
:......................................................................................
:......................................................................................
:.....................................................................................
:.....................................................................................
:.....................................................................................
:.....................................................................................
:.....................................................................................
:.....................................................................................

G. KETERANGAN TENTANG WALI

42. Nama :.....................................................................................

43. Tempat dan tanggal lahir :.....................................................................................
44. Agama :.....................................................................................
45. Kewarganegaraan :.....................................................................................
46. Pendidikan :.....................................................................................
47. Pekerjaan :.....................................................................................
48. Penghasilan per bulan :.....................................................................................
49. Alamat rumah :......................................................................................
50. Nomor Telepon/( Hp ) :.....................................................................................

H. KETERANGAN TENTANG KEGEMARAN SISWA

51. Kesenian :.....................................................................................

52. Olah raga :.....................................................................................
53. Berorganisasi :.....................................................................................
54. Lain-lain :.....................................................................................

Kediri,…………… 20..

Mengetahui, Yang membuat,

Orang Tua / Wali Murid

………………………… ……………………….

NB:

1. PENULISAN MEMAKAI HURUF KAPITAL/BALOK

2. MELAMPIRKAN FOTO COPI IJAZAH SD 1 LEMBAR