PEMERINTAH KABUPATEN BANJAR

DINAS PENDIDIKAN
KECAMATAN SIMPANG EMPAT
SEKOLAH DASAR NEGERI SUNGAI RAYA 1
NIS.100070 NSS.101150114007 NSPN.30300148
Alamat : Jl.Desa Sungai Raya Kec. Simpang Empat Kab.Banjar Kode Pos 70673

FORMULIR PENDAFTARAN SISWA BARU/PINDAHAN

TAHUN PELAJARAN 2022 / 2023

A. MURID
1. Nama Murid (Lengkap) :.................................................................................
2. NISN :.................................................................................
3. NIK :.................................................................................
4. Jenis Kelamin :.................................................................................
5. Tempat Tanggal Lahir :.................................................................................
6. Agama :.................................................................................
7. Anak Ke :.................................................................................
8. Status Dalam Keluarga :.................................................................................
9. Tinggal Bersama : 1) Orang Tua 2) Wali (Nenek atau lainnya……..)
10. Tinggi / Berat Badan :.................................................................................
11. Alamat Murid :.................................................................................
:.................................................................................
12. Jarak Rumah ke Sekolah :………..km
13. Transportasi ke Sekolah : 1) Jalan kaki 2) Bersepeda 3) Antar jemput

B. ORANG TUA/WALI
1. Nama Orang Tua
a. Ayah :.................................................................................
b. Ibu :.................................................................................
2. NIK
a. Ayah :.................................................................................
b. Ibu :.................................................................................
3. Tempat Tanggal Lahir
a. Ayah :.................................................................................
b. Ibu :.................................................................................
 4. Pendidikan
a. Ayah :.................................................................................
b. Ibu :.................................................................................
5. Pekerjaan
a. Ayah :.................................................................................
b. Ibu :.................................................................................
6. Penghasilan
a. Ayah : Rp...........................................................................
b. Ibu : Rp...........................................................................
7. Alamat Orang Tua :.................................................................................
:.................................................................................
8. No. Telp. Rumah / HP :.................................................................................
9. Nama Wali :.................................................................................
10. NIK :.................................................................................
11. Tempat Tanggal Lahir Wali :.................................................................................
12. Pendidikan Wali :.................................................................................
13. Pekerjaan Wali :.................................................................................
14. Penghasilan Perbulan :.................................................................................
15. Alamat Wali :.................................................................................
:.................................................................................
16. No. Telp. Rumah / HP :.................................................................................

C. PERNYATAAN
“Bersedia membimbing dan mengawasi calon murid yang tertera diatas untuk memenuhi
semua peraturan dan tata tertib sekolah, termasuk ketentuan mengenai PEMAKAIAN
SERAGAM SEKOLAH DAN TUGAS-TUGAS SEKOLAH”

Sungai Raya,………….……………2022
Orang Tua/Wali Murid

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