PEMERINTAH PROVINSI JAWA TENGAH

DINAS PENDIDIKAN DAN KEBUDAYAAN

SEKOLAH MENENGAH ATAS NEGERI 1
AJIBARANG
Alamat: Jln. Raya Pancurendang Ajibarang, Banyumas 53163 Telp. (0281) 571 807
Website: www.sman-ajibarang.sch.id Email: sman1ajibarang@gmail.com

DATA REGISTER PESERTA DIDIK BARU

SMA NEGERI 1 AJIBARANG
TAHUN PELAJARAN 2021/2022 Pasfoto
3x4
Dimohon mengisikan data-data di bawah ini menggunakan HURUF KAPITAL.

A. KETERANGAN DIRI SISWA

1. NIS Baru : ...........................................(diisi Petugas)
2. Nama Lengkap : ...........................................................................................
...........................................................................................
3. NISN : ...........................................................................................
4. Jenis Kelamin : ...........................................................................................
5. No. Induk Kependudukan (NIK) : ...........................................................................................
6. Tempat, Tanggal Lahir : ...........................................................................................
7. Agama : ...........................................................................................
8. Kewarganegaraan : WNI
9. Status dalam Keluarga : ...........................................................................................
10. Anak ke : ...........................................................................................
11. Jumlah Saudara Kandung : ...........................................................................................
12. Jumlah Saudara Tiri : ...........................................................................................
13. Jumlah Saudara Angkat : ...........................................................................................
14. Status Yatim/Piatu/Yatim Piatu : ...........................................................................................
15. Penerima KIP/PKH : Ya / Tidak (Pilih salah satu dengan cara melingkari)
16. No. KIP/PKH : ...........................................................................................
17. No. Telepon/HP : ...........................................................................................

B. KETERANGAN TEMPAT TINGGAL

18. Alamat Asal : ...........................................................................................
19. Alamat Kost : ...........................................................................................
20. Tinggal Bersama : ...........................................................................................
21. Jarak Rumah ke Sekolah : ...........................................................................................
22. Waktu Tempuh ke Sekolah : ...........................................................................................
23. Alat Transportasi : ...........................................................................................

C. KETERANGAN KESEHATAN
24. Golongan Darah
25. Riwayat Penyakit
26. Kelainan Jasmani
27. Tinggi Badan/Berat Badan
: ...........................................................................................
: ...........................................................................................
: ...........................................................................................
: .......................................... / .............................................

D. KETERANGAN PENDIDIKAN
28. Asal SMP/MTs
29. Tanggal dan Nomor Ijazah
30. Lama Belajar di SMP/MTs
31. Diterima di Kelas/Tanggal
: ...........................................................................................
: ...........................................................................................
: ...........................................................................................
: ........................................... / ............................................
 32. Penanggung Biaya : ...........................................................................................
33. Tempat Akses Internet : ...........................................................................................
34. Lama Akses Internet : ........................................... jam/hari

E. KEGEMARAN PESERTA DIDIK

35. Kesenian : ...........................................................................................
36. Olahraga : ...........................................................................................
37. Organisasi : ...........................................................................................
38. Kedudukan dalam Organisasi : ...........................................................................................
39. Frekuensi Rekreasi Keluarga : ...........................................................................................

F. KETERANGAN AYAH KANDUNG

40. Nama : ...........................................................................................
41. Tempat, Tanggal Lahir : ...........................................................................................
42. Agama : ...........................................................................................
43. Kewarganegaraan : WNI
44. Pendidikan Terakhir : ...........................................................................................
45. Pekerjaan : ...........................................................................................
46. Penghasilan per Bulan : ...........................................................................................
47. Alamat Rumah : ...........................................................................................
48. No. Telepon/HP : ...........................................................................................
49. Masih Hidup/Meninggal Tahun : ...........................................................................................

G. KETERANGAN IBU KANDUNG

50. Nama : ...........................................................................................
51. Tempat Tanggal Lahir : ...........................................................................................
52. Agama : ...........................................................................................
53. Kewarganegaraan : WNI
54. Pendidikan Terakhir : ...........................................................................................
55. Pekerjaan : ...........................................................................................
56. Penghasilan per Bulan : ...........................................................................................
57. Alamat Rumah : ...........................................................................................
58. No. Telepon/HP : ...........................................................................................
59. Masih Hidup/Meninggal Tahun : ...........................................................................................

Apabila peserta didik mengikuti Wali, mohon mengisi data di bawah ini.
H. KETERANGAN TENTANG WALI
60. Nama : ...........................................................................................
61. Tempat, Tanggal Lahir : ...........................................................................................
62. Agama : ...........................................................................................
63. Kewarganegaraan : WNI
64. Pendidikan Terakhir : ...........................................................................................
65. Pekerjaan : ...........................................................................................
66. Penghasilan per Bulan : ...........................................................................................
67. Alamat Rumah : ...........................................................................................
68. No. Telepon/HP : ...........................................................................................