FORMAT : S.

1 NPSN : 20202942

SURAT PENDAFTARAN SISWA BARU

TAHUN PELAJARAN 2023/2024
Nama Sekolah : SD NEGERI CIPARAY
Status Sekolah / Akreditasi : Negeri / B+
Desa : Ciparay
Kecamatan : Jampangkulon
Kabupaten : Sukabumi
Propinsi : Jawa Barat

A. KETERANGAN SISWA
1 Nama Lengkap : ….............................................................................................
2 Nama Panggilan : ….............................................................................................
3 Jenis Kelamin : Laki-Laki / Perempuan *)
4 Tempat, Tanggal Lahir : ….............................................................................................
5 Agama : ….............................................................................................
6 Anak Nomer ke : ….....................................................................(Dari Satu Ibu)
7 Banyak Saudara Kandung : ….............................................................................................
8 Banyak Saudara Tiri : ….............................................................................................
9 Banyak Saudara Angkat : ….............................................................................................
10 Berat Badan : ….............................................................................................
11 Tinggi Badan : ….............................................................................................
12 Penyakit Yang Pernah Diderita : ….............................................................................................
13 Alamat : ….............................................................................................
14 Bertempat tinggal pada : Orang Tua / Saudara / Menumpang / Asrama *)
B. ORANG TUA
1 a. Nama Ibu Kandung : ….............................................................................................
b. Tahun Lahir : ….............................................................................................
c. Pekerjaan : ….............................................................................................
d. Penghasilan Kotor/Bulan : ….............................................................................................
2 a. Nama Ayah Kandung : ….............................................................................................
b. Tahun Lahir : ….............................................................................................
c. Pekerjaan : ….............................................................................................
d. Penghasilan Kotor/Bulan : ….............................................................................................
C. ASAL MULA SISWA
1 a. Asal Siswa : Rumah Tangga / TK,SPS,KOBER, dll *)
b. Nama TK/SPS/KOBER,dll : ….............................................................................................
c. Kecamatan : ….............................................................................................
d. Kabupaten : ….............................................................................................
e. Propinsi : ….............................................................................................
2 Diterima di sekolah ini : ….............................................................................................
a. Tanggal : ….............................................................................................
b. di Kelas : ….............................................................................................
 Jampangkulon, …...............................................
Diterima / Ditolak *) Orang Tua / Wali *)
Alasan : …......................................................
Kepala Sekolah

…..................................................

MULYANA LESMANA, M.M.Pd

NIP. 197010202007011007