YAYASAN ANNUR SOWIJAYA

MADRASAH IBTIDAIYAH TERPADU ANNUR

NGABLAK KABUPATEN MAGELANG || NPSN: 69994001
Jl. Magelang – Kopeng KM.27 Kuncen Kec. Ngablak Kab. Magelang 56194
Email : mitannur1@gmail.com

Formulir Siswa
1. Data Anak
Nama Lengkap : ..............................................................................
Nama Panggilan : ..............................................................................
Tempat Tgl Lahir : ..............................................................................
Harap Ditempel
NIK Anak : ..............................................................................
Foto Berwarna
Agama : ..............................................................................
3x4
Warga Negara : ..............................................................................
Jenis Kelamin : ..............................................................................
Hobi : ..............................................................................
Cita-cita : .......................................................................................................
Anak Ke- : .......................................................................................................
Status dalam Keluarga : Anak Kandung Anak Angkat Anak Tiri Lainnya
Jumlah Saudara Kandung : .......................................................................................................
Nama Saudara Kandung :1. ....................................................................................................
(Ditulis Nama Lengkap 2. ....................................................................................................
3. ....................................................................................................
Jumlah Saudara Tiri :1. ....................................................................................................
(Ditulis Nama lengkap) 2. ....................................................................................................
3. ....................................................................................................
Bahasa Sehari-hari : .......................................................................................................
Berat Badan : .......................................................................................................
Tinggi Badan : .......................................................................................................
Golongan Darah : .......................................................................................................
Penyakit Berat Yang Diderita : .......................................................................................................
Alamat Tempat Tinggal : .......................................................................................................
No. Telepon / HP : .......................................................................................................
Pernah Mengukiti PAUD : Ya Tidak
Nama PAUD : .......................................................................................................

2. Informasi Orang Tua / Wali

a. No. KK : .......................................................................................................
Nama Ayah Kandung : .......................................................................................................
NIK Ayah : .......................................................................................................
Pendidikan Ayah : .......................................................................................................
Status Ayah Kandung : Masih Hidup Sudah Meninggal
Pekerjaan : .......................................................................................................
Penghasilan Ayah Per Bln: < Rp.500.000,-
Rp.500.000 – Rp.1.000.000
Rp.1.000.000 – Rp.2.000.000
> Rp.2.000.000
Alamat : .......................................................................................................
No. Telepon / HP : .......................................................................................................
b. Nama Ibu Kandung : .......................................................................................................
NIK Ibu : .......................................................................................................
Pendidikan Ibu : .......................................................................................................
Pekerjaan : .......................................................................................................
Penghasilan Ibu Per Bln : < Rp.500.000
Rp.500.000 – Rp.1.000.000
Rp.1.000.000 – Rp.2.000.000
> Rp.2.000.000
 Alamat : .......................................................................................................
No. Telepon / HP : .......................................................................................................
c. Nama Wali : .......................................................................................................
NIK Wali : .......................................................................................................
Pendidikan Wali : .......................................................................................................
Hubungan Terhadap Anak: .......................................................................................................
Pekerjaan : .......................................................................................................
Penghasilan Ibu Per Bln : < Rp.500.000
Rp.500.000 – Rp.1.000.000
Rp.1.000.000 – Rp.2.000.000
> Rp.2.000.000
Alamat : .......................................................................................................
No. Telepon / HP : .......................................................................................................

Data Penerimaan Bantuan

Status Penerimaan KKS/KPS : ...............................................................................
No. Kartu Keluarga Sejahtera(KKS) : ...............................................................................
Status keanggotaan PKH : ...............................................................................
Kelayakan PIP : ...............................................................................

3. Alamat Tempat Tinggal

Status Kepemilikan Rumah : Milik Sendiri Rumah Dinas
Rumah ortu Sewa/ Kontrak
Rumah Saudara Lainnya
Alamat : .......................................................................................................
Dusun : .......................................................................................................
Desa / Kelurahan : .......................................................................................................
Kecamatan : .......................................................................................................
Kode Pos : .......................................................................................................

4. Asal mula anak

a. Masuk madrasah ini sebagai : Siswa Baru Siswa Pindahan
b. Asal anak : Rumah Tangga RA TK
Nama sekolah : ...........................................................................................
NPSN sekolah : ...........................................................................................
Lama belajar : ...........................................................................................
c. Pindahan Dari ( hanya diisi oleh siswa pindahan )
Nama sekolah asal : ...........................................................................................
Tanggal : ...........................................................................................
Dari kelas : ...........................................................................................
d. Diterima di madrasah
Tanggal : ...........................................................................................
Di kelas : ...........................................................................................

Ngablak, ..............................2022

Kepala MIT Annur Orang Tua

Dian Hidayati Zuhria, S.Pd (.................................)