SEKOLAH DASAR ISLAM

AL ISTIQOMAH KENDARI
Kantor : Jl. Supu Yusuf No. 1 (Depan STIE 66 Kendari) Gedung LT. 4

FORMULIR PENDAFTARAN

DATA SISWA

Nama Lengkap : ......................................................................

Nama Panggilan : ......................................................................
Tempat Tanggal Lahir : ......................................................................
Umur : .................... Tahun ................ Bulan ...........
Jenis Kelamin :L/P
Agama : ......................................................................
Anak Ke : ........... Dari .............. Bersaudara
Status Anak : a. Kandung b. Tiri c. Anak Asuh
NIK (Kartu Keluarga ) : ......................................................................
Asal Sekolah : a. TK : ...............................................
b. Tidak TK
Alamat Lengkap
Jalan : .......................................................................
Kelurahan : .......................................................................
Kecamatan : .......................................................................
Kabupaten / Kota : .......................................................................
RT/RW : ........................................................................
Kode Pos : ........................................................................
Tinggi Badan : ........................................................................
Berat Badan : ........................................................................
Jarak Tempat Tinggal Ke Sekolah : ........................................................................
Alat Transportasi Kesekolah : a. Antar Jemput Mobil Pribadi
b. Antar Jemput Motor Pribadi
c. Ojek / Carteran
d. Angkutan Umum
Penyakit Ynag Pernah Diderita : ........................................................................
........................................................................
........................................................................
Penyakit Yang Sedang Diderita : ........................................................................
........................................................................
........................................................................
Kegemaran Anak : ........................................................................
........................................................................
........................................................................
Prestasi Yang Pernah Diraih : .......................................... Tahun ..................
.......................................... Tahun ..................
.......................................... Tahun ..................
.......................................... Tahun ..................
 SEKOLAH DASAR ISLAM
AL ISTIQOMAH KENDARI
Kantor : Jl. Supu Yusuf No. 1 (Depan STIE 66 Kendari) Gedung LT. 4

Lomba Yang Pernah Diikuti : ......................................... Tahun ...................

......................................... Tahun ...................
......................................... Tahun ...................
......................................... Tahun ...................
Minat dan Bakat Anak
a. Kelompok Seni : Menari, Musik, Menyanyi, Menggambar dan Melukis
b. Kelompok Olahraga : Karate, Silat, Taekwondo, Lari, Renang, Panahan
c. Kelompok Bahasa : Pidato, Puisi, Bercerita
d. Kelompo Sains : Matematika, Ipa, Robotik
e. Kursus / Privat yang pernah / sedang diikuti :
................................................................................................................................
................................................................................................................................
................................................................................................................................
................................................................................................................................
Makanan Kesukaan : ..........................................................................
Makanan Pantangan : ..........................................................................

Kendari, ................................ 20 .........

Orang Tua / Wali Siswa

(...........................................................)
 SEKOLAH DASAR ISLAM
AL ISTIQOMAH KENDARI
Kantor : Jl. Supu Yusuf No. 1 (Depan STIE 66 Kendari) Gedung LT. 4

IDENTITAS ORANG TUA / WALI SISWA

A. AYAH
Nama Lengkap : .............................................................
Tempat & Tanggal Lahir : .............................................................
Alamat Lengkap : .............................................................
Agama : .............................................................
Nomor Telpon : a). Rumah : ...................................
b). Kantor : ...................................
c). HP : ...................................
Pekerjaan : .............................................................
Alamat Kantor : .............................................................
Riwayat Pendidikan
1. TK : .............................................................
2. SD : .............................................................
3. SMP : .............................................................
4. SMA : .............................................................
5. Perguruan Tinggi : .............................................................
Penghasilan Perbulan : .............................................................

B. IBU
Nama Lengkap : .............................................................
Tempat & Tanggal Lahir : .............................................................
Alamat Lengkap : .............................................................
Agama : .............................................................
Nomor Telpon : a). Rumah : ...................................
b). Kantor : ...................................
c). HP : ...................................
Pekerjaan : .............................................................
Alamat Kantor : .............................................................
Riwayat Pendidikan
1. TK : .............................................................
2. SD : .............................................................
3. SMP : .............................................................
4. SMA : .............................................................
5. Perguruan Tinggi : .............................................................
Penghasilan Perbulan : .............................................................

Kendari, .........................................
Orang Tua / Wali Siswa

(.................................................)
 SEKOLAH DASAR ISLAM
AL ISTIQOMAH KENDARI
Kantor : Jl. Supu Yusuf No. 1 (Depan STIE 66 Kendari) Gedung LT. 4

DIISI JIKA ADA ORANG DEWASA YANG TINGGAL MENETAP BERSAMA CALON SISWA

Nama : .................................................................................
Tempat & Tanggal Lahir : .................................................................................
Suku / Warga Negara : .................................................................................
Agama : .................................................................................
Pekerjaan / Jabatan : .................................................................................
Pendidikan Terakhir : .................................................................................
Hubungan : .................................................................................

Nama : .................................................................................
Tempat & Tanggal Lahir : .................................................................................
Suku / Warga Negara : .................................................................................
Agama : .................................................................................
Pekerjaan / Jabatan : .................................................................................
Pendidikan Terakhir : .................................................................................
Hubungan : .................................................................................

Nama : .................................................................................
Tempat & Tanggal Lahir : .................................................................................
Suku / Warga Negara : .................................................................................
Agama : .................................................................................
Pekerjaan / Jabatan : .................................................................................
Pendidikan Terakhir : .................................................................................
Hubungan : .................................................................................

Nama : .................................................................................
Tempat & Tanggal Lahir : .................................................................................
Suku / Warga Negara : .................................................................................
Agama : .................................................................................
Pekerjaan / Jabatan : .................................................................................
Pendidikan Terakhir : .................................................................................
Hubungan : .................................................................................