YAYASAN BOLIYOHUTO CERDAS

SEKOLAH MENENGAH KEJURUAN (SMK) CENDEKIA BOLIYOHUTO

Akta Notaris Mohamad Nizar Mahmud.SH No.43 Tanggal 22 Maret 2011
Pengesahan Menteri Hukum dan Ham Nomor : AHU-283.AH.01.04.Tahun 2012
Alamat:
Jln. Rajawali Desa.Iloheluma Kec. Boliyohuto Kab. Gorontalo .Kode Pos 96261
E-mail : smkcendekiab@yahoo.com

BERITA ACARA PEMBINAAN PESERTA DIDIK BERMASALAH

No :620/SMK.Cend-Bol/ / /2019

Bahwa pada hari ini ............................ tanggal ……………………………. Bulan ........................... Tahun 2019
Pukul ..................... s/d pukul ......................, telah datang orang tua peserta didik dari
...................................................

Nama :
Kelas :
NIS/NISN :
Alamat :

Untuk membicarakan masalah perkembangan Pendidikan anak tersebut di atas, dengan orang
tua/wali siswa demi kelancaran dan perkembangan dalam proses belajar di sekolah.

...............................................................................................................................................................................................
...............................................................................................................................................................................................
..............................................................................................................................................................................................
...............................................................................................................................................................................................
...............................................................................................................................................................................................
..............................................................................................................................................................................................
...............................................................................................................................................................................................
...............................................................................................................................................................................................
...............................................................................................................................................................................................
...............................................................................................................................................................................................
...............................................................................................................................................................................................

Demikian berita acara ini dibuat dengan sebenarnya dalam keadaan sadar tanpa tekanan atau
paksaan dari siapapun dan pihak manapun.

Boliyohuto, 2019
Wali Kelas XI (Sebelas) Orang Tua Siswa/Wali
Tanda Tangan

………………………………….. ...............................................
Nip.-

Mengetahui
Kepala SMK Cendekia Boliyohuto

MUJIANTO MISIJAN.S.Pd
Nip : 196503241991031012
 YAYASAN BOLIYOHUTO CERDAS
SEKOLAH MENENGAH KEJURUAN (SMK) CENDEKIA BOLIYOHUTO
Akta Notaris Mohamad Nizar Mahmud.SH No.43 Tanggal 22 Maret 2011
Pengesahan Menteri Hukum dan Ham Nomor : AHU-283.AH.01.04.Tahun 2012
Alamat:
Jln. Rajawali Desa.Iloheluma Kec. Boliyohuto Kab. Gorontalo .Kode Pos 96261
E-mail : smkcendekiab@yahoo.com

BERITA ACARA KUNJUNGAN RUMAH/HOME VISIST

No :620/SMK.Cend-Bol/ / II/2019

Bahwa pada hari ini ............................ tanggal ……………………………. Bulan ........................... Tahun 2019
Pukul ..................... s/d pukul ......................, telah datang ......................................................
dan ................................................... untuk mengungunjungi rumah siswa :

Nama :
Kelas :
NIS/NISN :
Alamat :

Untuk membicarakan masalah perkembangan Pendidikan anak tersebut di atas, dengan orang
tua/wali siswa demi kelancaran dan perkembangan dalam proses belajar di sekolah.

...............................................................................................................................................................................................
...............................................................................................................................................................................................
..............................................................................................................................................................................................
...............................................................................................................................................................................................
...............................................................................................................................................................................................
..............................................................................................................................................................................................
...............................................................................................................................................................................................
...............................................................................................................................................................................................
...............................................................................................................................................................................................
...............................................................................................................................................................................................
...............................................................................................................................................................................................

Demikian berita acara ini dibuat dengan sebenarnya dalam keadaan sadar tanpa tekanan atau
paksaan dari siapapun dan pihak manapun.

Boliyohuto, 2019
Guru Yang Mengunjungi Orang Tua Siswa/Wali
Tanda Tangan

………………………………….. ...............................................
Nip.-

Mengetahui
Kepala SMK Cendekia Boliyohuto

MUJIANTO MISIJAN.S.Pd
Nip : 196503241991031012
 YAYASAN BOLIYOHUTO CERDAS
SEKOLAH MENENGAH KEJURUAN (SMK) CENDEKIA BOLIYOHUTO
Akta Notaris Mohamad Nizar Mahmud.SH No.43 Tanggal 22 Maret 2011
Pengesahan Menteri Hukum dan Ham Nomor : AHU-283.AH.01.04.Tahun 2012
Alamat:
Jln. Rajawali Desa.Iloheluma Kec. Boliyohuto Kab. Gorontalo .Kode Pos 96261
E-mail : smkcendekiab@yahoo.com

BERITA ACARA PERBAIKAN NILAI SEMESTER GANJIL

No :620/SMK.Cend-Bol/ / VII/2019

Bahwa pada hari ini ............................ tanggal ……………………………. Bulan ........................... Tahun 2019
Pukul ..................... s/d pukul ......................, telah datang orang tua siswa dari :

Nama :
Kelas :
NIS/NISN :
Alamat :

Untuk membicarakan masalah perkembangan Pendidikan anak tersebut di atas, dengan orang
tua/wali siswa demi kelancaran dan perkembangan dalam proses belajar di sekolah.

...............................................................................................................................................................................................
...............................................................................................................................................................................................
..............................................................................................................................................................................................
...............................................................................................................................................................................................
...............................................................................................................................................................................................
..............................................................................................................................................................................................
...............................................................................................................................................................................................
...............................................................................................................................................................................................
...............................................................................................................................................................................................
...............................................................................................................................................................................................
...............................................................................................................................................................................................

Demikian berita acara ini dibuat dengan sebenarnya dalam keadaan sadar tanpa tekanan atau
paksaan dari siapapun dan pihak manapun.

Boliyohuto, 8 Juli 2019

Wali Kelas X (Sepuluh) Orang Tua Siswa/Wali
Tanda Tangan

INDRI MAELASARI,S.Pd ...............................................

Nip.-

Mengetahui
Kepala SMK Cendekia Boliyohuto

MUJIANTO MISIJAN.S.Pd
Nip : 196503241991031012
 YAYASAN BOLIYOHUTO CERDAS
SEKOLAH MENENGAH KEJURUAN (SMK) CENDEKIA BOLIYOHUTO
Akta Notaris Mohamad Nizar Mahmud.SH No.43 Tanggal 22 Maret 2011
Pengesahan Menteri Hukum dan Ham Nomor : AHU-283.AH.01.04.Tahun 2012
Alamat:
Jln. Rajawali Desa.Iloheluma Kec. Boliyohuto Kab. Gorontalo .Kode Pos 96261
E-mail : smkcendekiab@yahoo.com

BERITA ACARA PENARIKAN SISWA PESERTA PRAKERIN

No :620/SMK.Cend-Bol/ / IV/2019

Bahwa pada hari ini ............................ tanggal ……………………………. Bulan ........................... Tahun 2019
Pukul ..................... s/d pukul ......................, telah datang ......................................................
dan ................................................... untuk Menarik siswa Peserta PRAKERIN (Praktek Kerja Industri) :

Nama :
Kelas :
NIS/NISN :
Alamat :
...............................................................................................................................................................................................
...............................................................................................................................................................................................
..............................................................................................................................................................................................
...............................................................................................................................................................................................
...............................................................................................................................................................................................
..............................................................................................................................................................................................
...............................................................................................................................................................................................
...............................................................................................................................................................................................
...............................................................................................................................................................................................
...............................................................................................................................................................................................
...............................................................................................................................................................................................
...............................................................................................................................................................................................
...............................................................................................................................................................................................
...............................................................................................................................................................................................
...............................................................................................................................................................................................
...............................................................................................................................................................................................
...............................................................................................................................................................................................

Demikian berita acara ini dibuat dengan sebenarnya dalam keadaan sadar tanpa tekanan atau
paksaan dari siapapun dan pihak manapun.

Boliyohuto, 2019
Guru Pembimbing Sekolah Ketua Panitia PRAKERIN
Tanda Tangan

MASRIN HASAN,S.Pd FITRIAN EVA TAMALA, SP

Nip.- Nip.-

Mengetahui
Kepala SMK Cendekia Boliyohuto

MUJIANTO MISIJAN.S.Pd
Nip : 196503241991031012
 YAYASAN BOLIYOHUTO CERDAS
SEKOLAH MENENGAH KEJURUAN (SMK) CENDEKIA BOLIYOHUTO
Akta Notaris Mohamad Nizar Mahmud.SH No.43 Tanggal 22 Maret 2011
Pengesahan Menteri Hukum dan Ham Nomor : AHU-283.AH.01.04.Tahun 2012
Alamat:
Jln. Rajawali Desa.Iloheluma Kec. Boliyohuto Kab. Gorontalo .Kode Pos 96261
E-mail : smkcendekiab@yahoo.com

BERITA ACARA PENYERAHAN KEMBALI SISWA KEPADA ORANG TUA/WALI

No :620/SMK.Cend-Bol/ / I/2020

Bahwa pada hari ini ............................ tanggal ……………………………. Bulan ........................... Tahun 2020
Pukul ..................... s/d pukul ......................, telah datang Guru ......................................................
dan ................................................... untuk Mengembalikan siswa Peserta Didik SMK CENDEKIA
BOLIYOHUTO kepada Orang Tua/ Wali :

Nama :
Kelas :
NIS/NISN :
Alamat :
...............................................................................................................................................................................................
...............................................................................................................................................................................................
..............................................................................................................................................................................................
...............................................................................................................................................................................................
...............................................................................................................................................................................................
..............................................................................................................................................................................................
Bardasarkan surat pernyataan siswa tersebut diatas serta orang tuanya tertanggal 10 Januari 2020,
maka dengan ini kami mengembalikan siswa tersebut kepada orang tuanya untuk dibimbing dalam
oleh orang tua untuk jangka waktu tertentu.
Demikian berita acara ini dibuat dengan sebenarnya dalam keadaan sadar tanpa tekanan atau
paksaan dari siapapun dan pihak manapun.

Boliyohuto, Januari 2020

Kepala SMK Cendekia Boliyohuto

MUJIANTO MISIJAN.S.Pd
Nip : 196503241991031012
 SURAT PERNYATAAN ORANG TUA/WALI SISWA

Saya yang bertanda tangan di bawah ini :

Nama                              : …………………………………
Tempat / Tgl. Lahir         : …………………………………
Jenis Kelamin                  : …………………………………
Alamat                             : …………………………………

Saya orang tua siswa dari RATNA KUYU’U, Kelas XI (Sebelas) SMK Cendekia
Boliyouto menyatakan dengan sungguh-sungguh bahwa anak saya tersebut di atas sudah tidak
mau melanjutkan pendidikannya lagi di SMK Cendekia Boliyohuto, oleh karena itu saya tidak
keberatan jika anak saya akan di kembalikan kepada kami selaku orang tuanya.
Demikianlah surat pernyataan ini saya buat dalam keadaan sadar sesadar-sadarnya tanpa
ada paksaan dari pihak manapun, dan untuk digunakan sebagaimana mestinya.
                                    
Boliyohuto, Januari 2020

Yang membuat pernyataan,

……………………….

Disaksikan Oleh :

Guru BK      Wali Kelas

ERLIS PULUBUHU, SH                          MASRIN HASAN, S.Pd

NIP. -                         NIP. -

Mengetahui
Kepala SMK Cendekia Boliyohuto

MUJIANTO MISIJAN.S.Pd
Nip : 196503241991031012
 SURAT PERNYATAAN SISWA

Saya yang bertanda tangan di bawah ini :

Nama                              : RATNA KUYU’U

Tempat / Tgl. Lahir         :
Nama Ayah                     :
Nama Ibu                         :
NIS                                 : 101
Jenis Kelamin                  : Perempuan
Kelas                                : XI (Sebelas)
Alamat                             : Desa Iloheluma, Kec. Boliyohuto, Kab. Gorontalo
Saya menyatakan dengan sungguh-sungguh bahwa saya tidak akan melanjutkan lagi
pendidikan di SMK Cendekia Boliyohuto dengan alasan tidak mau mengikuti kegiatan Praktek
Kerja Industri (PRAKERIN), dan saya tidak akan keberatan jika pihak sekolah mengembalikan
saya ke orang tua.
Demikianlah surat pernyataan ini saya buat dalam keadaan sadar sesadar-sadarnya tanpa
ada paksaan dari pihak manapun, dan untuk digunakan sebagaimana mestinya.
                          
Boliyohuto, Januari 2020

Yang membuat pernyataan,

RATNA KUYU’U

Disaksikan Oleh :

Guru BK      Wali Kelas

ERLIS PULUBUHU, SH                          MASRIN HASAN, S.Pd

NIP. -                         NIP. -

Mengetahui
Kepala SMK Cendekia Boliyohuto

MUJIANTO MISIJAN.S.Pd
Nip : 196503241991031012
 SURAT PERNYATAAN ORANG TUA/WALI SISWA

Saya yang bertanda tangan di bawah ini :

Nama                              : …………………………………
Tempat / Tgl. Lahir         : …………………………………
Jenis Kelamin                  : …………………………………
Alamat                             : …………………………………
...............................................................................................................................................................................................
...............................................................................................................................................................................................
..............................................................................................................................................................................................
...............................................................................................................................................................................................
...............................................................................................................................................................................................
..............................................................................................................................................................................................
...............................................................................................................................................................................................
...............................................................................................................................................................................................
...............................................................................................................................................................................................
...............................................................................................................................................................................................
...............................................................................................................................................................................................
...............................................................................................................................................................................................
...............................................................................................................................................................................................
...............................................................................................................................................................................................
...............................................................................................................................................................................................
...............................................................................................................................................................................................
                                  
Boliyohuto,
Januari 2020

Yang membuat pernyataan,

……………………….

Disaksikan Oleh :

Guru BK      Wali Kelas

ERLIS PULUBUHU, SH                          MASRIN HASAN, S.Pd

NIP. -                         NIP. -

Mengetahui
Kepala SMK Cendekia Boliyohuto

MUJIANTO MISIJAN.S.Pd
Nip : 196503241991031012
 SURAT PERNYATAAN SISWA

Saya yang bertanda tangan di bawah ini :

Nama                              : RATNA KUYU’U

Tempat / Tgl. Lahir         : Parungi, 29 November 2002
Nama Ayah                     :
Nama Ibu                         :
NIS                                 : 101
Jenis Kelamin                  : Perempuan
Kelas                                : XI (Sebelas)
Alamat                             : Desa Iloheluma, Kec. Boliyohuto, Kab. Gorontalo
...............................................................................................................................................................................................
...............................................................................................................................................................................................
..............................................................................................................................................................................................
...............................................................................................................................................................................................
...............................................................................................................................................................................................
..............................................................................................................................................................................................
...............................................................................................................................................................................................
...............................................................................................................................................................................................
...............................................................................................................................................................................................
...............................................................................................................................................................................................
...............................................................................................................................................................................................
...............................................................................................................................................................................................
...............................................................................................................................................................................................
...............................................................................................................................................................................................
...............................................................................................................................................................................................
...............................................................................................................................................................................................

Boliyohuto, Januari 2020

Yang membuat pernyataan,

RATNA KUYU’U

Disaksikan Oleh :

Guru BK      Wali Kelas

ERLIS PULUBUHU, SH                          MASRIN HASAN, S.Pd

NIP. -                         NIP. -

Mengetahui
Kepala SMK Cendekia Boliyohuto

MUJIANTO MISIJAN.S.Pd
Nip : 196503241991031012