SURAT PERNYATAAN

Yang bertanda tangan di bawah ini

nama : ................................................................................
kelas : ................................................................................

telah melakukan pelanggaran berupa:

1. ...........................................................................................................................
2. ............................................................................................................................
3. ............................................................................................................................
4. ............................................................................................................................
5. .............................................................................................................................

Berdasarkan hal tersebut di atas, saya menyatakan dengan sebenar-benarnya, jika melanggar tata tertib
lagi bersedia untuk
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Mengetahui Dampit, .......................................

Orang tua/ Wali, Siswa yang bersangkutan,

....................................... ...................................................
Mengetahui
.............................................................

.................................................
NIP ........................................
 DATA PELANGGARAN DAN PENANGANANNYA

Nama : ...................................................... Kelas : ..................................

Tanda tangan Penanganan *1)
No Uraian pelanggaran Hari/ Tanggal Keterangan *2)
Siswa Piket Wali kelas BK/ Tatib

Keterangan : *1) Diisi parap petugas dan tanggal penanganan (Wali kelas/ BK/ Tatib)
*2 )
Diisi hasil/tindak lanjut penanganan oleh Wali kelas/ BK/ Tatib
 SMA NEGERI 1 DAMPIT
JURNAL KEGIATAN BELAJAR MENGAJAR

Mata Pelajaran : .............................................................. Semester/ Tahun: .........................................................

Hari/ Tanggal Jam ke- Kelas Materi Pelajaran Siswa Absen Keterangan