KETERANGAN TENTANG DIRI SISWA

1. Nama Anak Didik : .................................................................

a. Nama Lengkap : .................................................................
b. Nama Panggil : .................................................................
2. Nomor Induk : …………………………………………..
3. Jenis Kelamin : Laki-laki/Perempuan*)
4. Tempat dan Tanggal Lahir : .................................................................
5. Agama : .................................................................
6. Anak ke : .................................................................
7. Nama Orang Tua/Wali*)
a. Ayah : .................................................................
b. Ibu : .................................................................
8. Pekerjaan Orang Tua/Wali*)
a. Ayah : .................................................................
b. Ibu : .................................................................
9. Alamat Orang Tua/Wali*)
a. Jalan : .................................................................
: .........................Telp.................................
b. Desa/Kelurahan : .................................................................
c. Kecamatan : .................................................................
d. Kabupaten/Kota*) : .................................................................
e. Propinsi : .................................................................

Bajawa, …………………........20…
Kepala TKK Negeri Beiposo
Pas Foto

3X4

MARIA GORETI MENGE, S.Pd

NIP. 19660203 200112 2 003
 LAPORAN PERKEMBANGAN ANAK DIDIK
Nama : .................................................... Usia : ..........................
Nomor Induk : .................................................... Semester : ..........................
Kelompok : .................................................... Tahun Pelajaran : ..........................
A. PENDAHULUAN
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PERTUMBUHAN ANAK
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 KETERANGAN PINDAH TK

Diisi Oleh : TKK Lama

Nama Anak : ..............................................................................
Nomor Induk : ..............................................................................

Sebab keluar dan Tanda tangan Kepala TKK,

Kelas yang
Tanggal atas permintaan Stempel TKK, dan Tanda
ditinggalkan
(tertulis) dari tangan Orang Tua/Wali
...........................................
Kepala TKK

(.............................................)
Orang Tua / Wali

(.............................................)
...........................................
Kepala TKK

(.............................................)
Orang Tua / Wali

(.............................................)
...........................................
Kepala TKK

(.............................................)
Orang Tua / Wali

(.............................................)
...........................................
Kepala TKK

(.............................................)
Orang Tua / Wali

(.............................................)