DATA PRIBADI PESERTA DIDIK

SMA NEGERI 1 LILIRIAJA KAB. SOPPENG

TAHUN PELAJARAN ........ / ........

A. KETERANGAN PRIBADI
1.Nama Lengkap : ...................................................................................................
2.Jenis Kelamin : ...................................................................................................
3.Tempat dan Tangal Lahir : ...................................................................................................
4.Agama : ...................................................................................................
5.Kewarganegaraan : ...................................................................................................
6.Anak keberapa : ...................................................................................................
7.Jumlah saudara kandung : ...................................................................................................
8.Jumlah saudara tiri : ...................................................................................................
9.Anak yatim / piatu / yatim piatu : ...................................................................................................
10. Bahasa sehari-hari di rumah : ...................................................................................................
B. KETERANGAN TEMPAT TINGGAL
11. Alamat : ...................................................................................................
12. Nomor Telepon/HP : ...................................................................................................
13. Alamat tersebut : a. Tempat tinggal orang tua
Bersama ..............................................................................
b. Menumpang pada orang lain
Bersama ..............................................................................
14. Jarak dari tempat tinggal ke sekolah : ...................................................................................................
15. Ke sekolah dengan :  Kendaraan umum
 Kendaraan Pribadi
 Jalan kaki
C. KETERANGAN KESEHATAN
16. Golongan darah/kelainan jasmani : ...................................................................................................
17. Tinggi dan berat badan siswa : ...................................................................................................
D. KETERANGAN PENDIDIKAN SEBELUMNYA
18 Asal sekolah : ...................................................................................................
19 NISN : ..................................................................................................
20 No.Peserta UN SMP : ..................................................................................................
21 Pindah dari sekolah : ...................................................................................................
Diterima di sekolah ini tanggal : ...................................................................................................

E. KETERANGAN ORANG TUA KANDUNG

NO ORANG TUA KANDUNG AYAH IBU

20 Nama ...................................................... .....................................................

21 Tempat dan tanggal lahir ...................................................... ......................................................
22 Agama ...................................................... ......................................................
23 Kewarganegaraan ...................................................... ......................................................
24 Ijazah tertinggi ...................................................... ......................................................
25 Pekerjaan ...................................................... ......................................................
26 Penghasilan/bulan ...................................................... ......................................................
27 Alamat rumah/no.Telp./HP ...................................................... ......................................................
28 Masih hidup/meninggal ...................................................... ......................................................