Anak Ke : ...........................................................................................
Alamat : ...........................................................................................
Telepon / HP : ...........................................................................................
Asal Sekolah : ...........................................................................................
Penyakit yang pernah diderita/masih : .............................................................................
Nama Orangtua : ...........................................................................................
1. Ayah : ...........................................................................................
Pekerjaan : ...........................................................................................
Pendidikan terakhir : ...........................................................................................
2. Ibu : ...........................................................................................
Pekerjaan : ...........................................................................................
Pendidikan terakhir : ...........................................................................................
Penghasilan Orangtua : Rp ..........................................................
Alamat Orangtua : ...........................................................................................
Persyaratan :
No Persyaratan Keterangan
1 Photo 3x4 hitam putih 4 lembar berseragam sekolah
(khusus calon siswa perempuan wajib berkerudung)
2 Photo copy STTB Dan SKHUN atau keterangan duduk
di kelas VI SD/ MI
3 Photo copy Akta Kelahiran
4 Photo copy NISN (kartu biru)
5 Photo copy Kartu KJS/ PKH, KIP Dsb.
6 Photo copy Ijazah TPA
( .................................................... ) ( .................................................... )