A. KETERANGAN MURID
1. Nama Siswa : ............................................................................
2. NISN : ............................................................................
3. NIK : ............................................................................
4. Tempat Tanggal/ Lahir : ............................................................................
5. Agama : ............................................................................
6. Status Dalam Keluarga : ............................................................................
7. Anak Ke / Jumlah saudara : ....................................../.....................................
8. Bahasa sehari – hari : ............................................................................
9. Tinggi / Berat Badan : ...........................cm / ................................kg
10. Alamat Rumah : ...........................................................................
...........................................................................
11. Jarak dari rumah ke sekolah : ...........................................................................
12. Alat Transportasi yang Digunakan: .........................................................................
D. PERKEMBANGAN MURID
1. Asal Sekolah (SD/MI) : ..........................................................................
2. Di terima di sekolah ini tanggal : ..........................................................................
Pangandaran, 2020
Peserta Didik Orang Tua/ Wali
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