Nomor Pendaftaran : ……… Nomor Statistik Sekolah

1 0 1 1 2 4 0 1 2 0 1 6
NAMA SEKOLAH : SDN 1 KARANG AGUNG
STATUS SEKOLAH : NEGERI / IMPRES
ALAMAT SEKOLAH : KARANG AGUNG
DESA / PEKON : KARANG AGUNG
KECAMATAN : WAY TENONG
KABUPATEN : LAMPUNG BARAT
PROVINSI : LAMPUNG
FORMULIR PENDAFTARAN MURID BARU TAHUN PELAJARAN 2021/2022
A. KETERANGAN ANAK
1. Nama Lengkap :.....................................................................................................................................
2. Nama Panggilan :.....................................................................................................................................
3. Jenis Kelamin :.....................................................................................................................................
4. Tempat dan Tanggal Lahir :.....................................................................................................................................
5. Agama :.....................................................................................................................................
6. Kewarganegaraan :.....................................................................................................................................
7. Anak Ke :.....................................................................................................................................
8. Banyak Saudara Kandung :.....................................................................................................................................
9. Banyak Saudara Tiri :.....................................................................................................................................
10. Banyak Saudara Angkat :.....................................................................................................................................
11. Bahasa Sehari – hari :.....................................................................................................................................
12. Berat Badan :.....................................................................................................................................
13. Tinggi Badan :.....................................................................................................................................
14. Golongan Darah :.....................................................................................................................................
15. Penyakit Yang Pernah diderita :.....................................................................................................................................
16. Alamat Tempat Tinggal :.....................................................................................................................................
17. Bertempat Tinggal Pada :.....................................................................................................................................
18. Apakah Penerima KPS / PKH : No /KPS/PKH :..............................................................................................................
19. No Tlpn :………………………………………………………………………………………………………………………………..
20. NIS / NISN :………………………………………………………………………………………………………………………………..
B. Orang Tua / Wali
21. Nama a. Ayah Kandung :.....................................................................................................................................
b. NIK KTP :.....................................................................................................................................
c. Alamat :.....................................................................................................................................
22. Nama a. Ibu Kandung :.....................................................................................................................................
b. NIK KTP : ....................................................................................................................................
c. Alamat : ....................................................................................................................................
23. Pekerjaan a. Ayah Kandung :.....................................................................................................................................
b. Ibu Kandung : ....................................................................................................................................
24. Nama Wali Murid : ....................................................................................................................................
25. Pendidikan Tertinggi : ....................................................................................................................................
Hubungan Terhadap Anak :.....................................................................................................................................
26. Pekerjaan : ....................................................................................................................................
C. ASAL ANAK ( KELUARGA , PAUD , TK )
27. Asal Sekolah :.....................................................................................................................................
28. Nama TK :.....................................................................................................................................
29. Tahun Dan NO STTB :.................:...................................................................................................................
30. Lama Belajar :......................:..............................................................................................................
D. DITERIMA DISEKOLAH INI
31. Tanggal dIterima :.....................................................................................................................................
32. Di Tingkat :............................:........................................................................................................

Karang Agung, ...................... 2021

Kepala SDN 1 Karang Agung Orang Tua / Wali

BAHROPI, S.Pd ( ..................................... )

Nip. 197003161994081001

Syarat pendaftaran :
1. Pendaftaran Dibuka Dari Tanggal 1 – 10 Juli 2021
2. Calon Peserta Didik Baru Berusia Minimal 6 Th Pada Tanggal 1 Juli 2021
3. FotoCopy Akte Kelahiran
4. FotoCopy KK
5. FotoCopy Ijazah Jika ada
6. KIA ( Jika Ada )
7. FotoCopy KTP Ayah dan Ibu
8. Mengisi Formulir Pendaftaran