FORMULIR PENDAFTARAN MASUK SEKOLAH
TINGKAT PENDIDIKAN TK/TPA/MTS DAN MA
DAYAH MODERN TERPADU SUBULUSSALAM-JONTOR
A. Keterangan pribadi
1. Nama
a. Nama Lengkap
b. Nama Panggilan
c. NISN
2. Jenis Kelamin
3. Tempat Tgl Lahir
4. Agama
5. Kewarganegaraan
6. Anak Ke
7. Jumlah Saudara kandung
8. Jumlah Saudara Angkat
9. Anak Yatim/ Piatu/
Yatim piatu
10. Bahasa Sehari-Hari
Dirumah
B. Keterangan Tempat Tinggal
11. Alamat Rumah
12. Tinggal Pada
13. Kesekolah Menggunakan
C. Keterangan Kesehatan
14. Berat dan Tinggi Badan
15. Penyakit Yang Pernah
Diderita
16. Kelainan Jasmani
D. Keterangan Pendidikan Sebelumnya
17. Asal Sekolah
a. TK/SD/Tsanawiyah
b. Tanggal dan No. STTB
c. Lama Belajar
18. Pindah Dari sekolah
19. Diterima disekolah ini tgl
20. Di Kelas
E. Keterangan Orang Tua/Wali
21. Nama Orang
22. Nama Wali
23. Alamat Orang Tua/Wali
24. Nomor Telepon/ HP
25. Tempat/ Tanggal Lahir Ayah
26. Tempat/ Tanggal LahirI Ibu
27. Pekerjaan Orang Tua/ Wali
28. Jumlah/ Penghasiln Orang Tua/ Wali : ...........................................................................
29. Pendidikan Tertinggi
Ayah/ Wali
Ibu/ Wali
Mengetahui
Orang Tua/Wali Calon Siswa
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TAHUN PELAJARAN 2020-2021
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Jontor, ............................
Tanda Tangan Calon Siswa
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