LEMBAGA PENDIDIKAN MA’ARIF NU

MADRASAH IBTIDAIYAH HIDAYATUL ULUM

STATUS : TERAKREDITASI “A”
NSM : 111235230044 / NPSN : 60718245
Alamat : Jl. Pemuda 01 Ds. Talun, kecamatan Montong, kab. Tuban Telp. ( 082331900816 )

FORMULIR PENDAFTARAN SISWA BARU

TAHUN PELAJARAN 2020/2021
I. SISWA
1. Nama Lengkap : ......................................................................................
2. Jenis Kelamin : ......................................................................................
3. Tempat Lahir & Tanggal Lahir : ......................................................................................
4. Agama : ......................................................................................
5. Anak ke : ......................................................................................
6. Status Dalam keluarga : ......................................................................................
7. Alamat : ......................................................................................
Telepon : ......................................................................................
8. Diterima di Madrasah ini
a. Di kelas : ......................................................................................
b. Pada Tanggal : ......................................................................................
c. Surat Pindah : ......................................................................................
9. Sekolah Asal : ......................................................................................
a. Nama Play Group : ......................................................................................
b. Alamat : ......................................................................................
II. ORANG TUA / WALI MURID
10. Nama Orang Tua : ......................................................................................
a. Ayah : ......................................................................................
b. Ibu : ......................................................................................
11. Agama Orang Tua : ......................................................................................
12. Alamat Orang Tua : ......................................................................................
13. Pekerjaan Orang Tua : ......................................................................................
a. Ayah : ......................................................................................
b. Ibu : ......................................................................................
14. Pendidikan Ayah : ......................................................................................
15. Pendidikan Ibu : ......................................................................................
16. Nama Wali : ......................................................................................
17. Agama Wali : ......................................................................................
18. Alamat Wali : ......................................................................................
19. Telepon : ......................................................................................
20. Pekerjaan Wali : ......................................................................................
Diperiksan Oleh Talun, ....................... 2020
Kepala MI. Hidayatul Ulum Orang Tua / Wali Murid

GHUFRON, S.Pd .............................................

NB : Formulir ini diisi oleh Orang Tua/Wali Murid, pengisian identitas harus benar sesuai dengan
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