PEMERINTAH KABUPATEN BARITO SELATAN
DINAS PENDIDIKAN
SMP NEGERI 8 DUSUN SELATAN
Alamat : Jalan Asam No. 339 Rt. 06 Penda Asam73752
FORMULIR DAFTAR ULANG PESERTA DIDIK
TAHUN PELAJARAN 2019/2020
A. KETERANGAN TENTANG DIRI SISWA
1. Nama Siswa
a. Nama Lengkap
b. Nama Panggilan
2. Jenis Kelamin
3. Tempat dan Tanggal Lahir
4. Agama
5. Kewarganegaraan
6. Anak Keberapa
7. Jumlah Saudara Kandung
8. Jumlah Saudara Tiri
9. Jumlah Saudara Angkat
10. Anak Yatim / Piatu / Yatim Piatu
11. Bahasa sehari-hari di rumah
B. KETERANGAN TEMPAT TINGGAL
12. Alamat
13. Nomor Telepon / Hp
14. Tinggal dengan Orang Tua/
Saudara/ Di Asrama/ Kost
15. Jarak tempat tinggal ke sekolah
C. KETERANGAN KESEHATAN
16. Golongan Darah
17. Penyakit yang pernah diderita,
TBC, Cacar / Malaria dan lain2
18. Kelainan Jasmani
19. Tinggi dan berat badan
D. KETERANGAN PENDIDIKAN
20. Pendidikan sebelumnya
a. Lulus dari
b. Tanggal dan Nomor STTB
c. Lama Belajar
E. KETERANGAN TENTANG AYAH KANDUNG
21. Nama
22. Tempat dan Tanggal Lahir
23. Agama
24. Kewarganegaraan
25. Pendidikan
28. Pekerjaan
29. Penghasilan per bulan
30. Alamat Rumah/ Nomor Telpon (Hp)
31. Masih Hidup/ Meninggal Dunia Tahun
F. KETERANGAN TENTANG IBU KANDUNG
32. Nama
33. Tempat dan Tanggal Lahir
34. Agama
35. Kewarganegaraan
Nomor Pendaftaran
Ulang
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 36. Pendidikan : ...............................................................................................................
37. Pekerjaan : ...............................................................................................................
38. Penghasilan per Bulan : ...............................................................................................................
39. Alamat Rumah/ Nomor Telpon (Hp) ...............................................................................................................
40. Masih Hidup/ Meninggal Dunia Tahun ...............................................................................................................
G. KETERANGAN TENTANG WALI
41. Nama : ...............................................................................................................
42. Tempat dan Tanggal Lahir : ...............................................................................................................
43. Agama : ...............................................................................................................
44. Kewarganegaraan : ...............................................................................................................
45. Pendidikan : ...............................................................................................................
46. Pekerjaan : ...............................................................................................................
47. Penghasilan per Bulan : ...............................................................................................................
48. Alamat Rumah/ Nomor Telpon (Hp) : ...............................................................................................................
H. KEGEMARAN SISWA
49. Kesenian : ...............................................................................................................
50. Olah Raga : ...............................................................................................................
51. Kemasyarakatan / Organisasi : ...............................................................................................................
52. Lain - lain : ...............................................................................................................

Catatan :
 Lampiran yang diserahkan bersama formulir daftar ulang :
Fotocopy Kartu Indonesia Pintar ( Jika menerima)sebanyak 1 lembar
 Untuk perempuan stopmap merah dan untuk laki-laki stopmap biru

Penda Asam, 2019

Diketahui oleh :
Orang Tua/Wali murid Peserta Didik

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