‫معهد البرهان اإلسالمى‬

SD TAHFIDZ AL-WILDAN WATULIMO

Sekretariat : Jl. Pantai Prigi – Margomulyo, Watulimo, Trenggalek Kode Pos. 66382
 : 081228116505 E-mail : sdta.alwildan@gmail.com

FORMULIR PENDAFTARAN
TAHUN PELAJARAN 2022/2023
I. DATA PRIBADI
1. Nama Lengkap (Sesuai Akte Lahir) :...............................................................................
2. Nama Panggilan :...............................................................................
3. Jenis Kelamin :...............................................................................
4. Tempat dan Tanggal Lahir :...............................................................................
5. Agama / Kepercayaan :...............................................................................
6. Kewarganegaraan :...............................................................................
7. Anak ke berapa :...............................................................................
8. Anak yatim/piatu/yatim piatu :...............................................................................
9. Alamat lengkap dari siswa :...............................................................................
RT/RW :...............................................................................
Kel/Kec. :………………………...........................................
Kabupaten :...............................................................................
No.HP :...............................................................................
10. Jarak tempat tinggal ke sekolah :...............................................................................
11. Ke sekolah dengan kendaraan :...............................................................................
12. Berat badan waktu mendaftar :............................................................................ kg.
13. Tinggi badan waktu mendaftar :............................................................................ cm
14. Golongan darah :...............................................................................
15. Penyakit yang pernah diderita : ……………………………./ Kelainan jasmani / lainnya.

II. DATA ORANG TUA

1. Nama Ayah :...............................................................................
2. Tempat tanggal lahir Ayah :...............................................................................
3. Nama Ibu :...............................................................................
4. Tempat tanggal lahir Ibu :...............................................................................
5. Nama Wali :...............................................................................
6. Alamat Orangtua/Wali :...............................................................................
RT/RW :...............................................................................
Kec./Kel. :………………………...........................................
Kabupaten :...............................................................................
No.HP :...............................................................................
7. Pekerjaan Orangtua/Wali :...............................................................................
 8. Tanggungan anak yang masih sekolah :
No Nama Umur Sekolah di Kelas Keterangan

1.

2.

3.

4.

5.

III. KETERANGAN LAIN :

1. Asal sekolah TK :...............................................................................
2. Alamat TK :...............................................................................
3. Bakat khusus/Prestasi :...............................................................................
 Kesenian :...............................................................................
 Olahraga :...............................................................................
 Kemasyarakatan :...............................................................................
 Hasil Karya: :...............................................................................
4. Nomor STTB TK Tahun :...............................................................................
5. Intelegensi (IQ) :...............................................................................
IV. PERSYARATAN
1. Foto Copy Akte : ada / belum
2. Foto Copy Kartu Keluarga : ada / belum
3. Foto Copy KIA : ada / belum
4. Foto Copy Ijazah TK : ada / belum

Watulimo, ……………………………..
Orang Tua / Wali Siswa

(……………………………)
NO. PENDAFTARAN : …………………..
FORM. PENDAFTARAN : SD
UANG PENDAFTARAN : Gratis ( Free )