RAUDLATUL ATHFAL PERSATUAN ISLAM 121

AN NUR
Dusun Cipedang (Gelam) Desa Sukamulya Kecamatan Baregbeg Kabupaten Ciamis 46274

FORMULIR PENDAFTARAN CALON PESERTA DIDIK BARU

I. IDENTITAS SISWA
1. Nama : ..........................................................................................
2. Jenis kelamin : Laki-laki / Perempuan
3. Tempat dan Tanggal Lahir : ...........................................................................................
4. Agama : ...........................................................................................
5. Anak ke : ...........................................................................................
6. Status dalam keluarga : sulung / bungsu / tunggal*
7. No. KK : ..........................................................................................
8. NIK : ..........................................................................................
9. Alamat
a. Dusun : ........................................................ RT .......... RW .........
b. Desa : ...........................................................................................
c. Kecamatan : ...........................................................................................
d. Kabupaten : ...........................................................................................
10. Diterima di Raudlatul Athfal ini
a. Di kelompok : ...........................................................................................
b. Pada Tanggal : ...........................................................................................
c. Untuk selama : ...........................................................................................
II. IDENTITAS ORANG TUA /
WALI
11. Nama Orang Tua
a. Ayah Kandung/ Wali : ...........................................................................................
b. NIK : ...........................................................................................
c. No. Telepon Seluler :...........................................................................................
No. Whatsapp :...........................................................................................
d. Ibu Kandung/ Wali : ...........................................................................................
e. NIK : ...........................................................................................
f. No. Telpon seluler :............................................................................................
No. Whatsapp :.............................................................................................
12. Alamat Orang Tua
a. Dusun : ........................................................... RT ......... RW .......
b. Desa : ...........................................................................................
c. Kecamatan : ...........................................................................................
d. Kabupaten : ...........................................................................................
13. Pekerjaan Orang Tua/ Wali
a. Ayah Kandung/ Wali : ...........................................................................................
b. Ibu Kandung / Wali : ...........................................................................................

*coret yang tidak perlu Cipedang, ................................................ 20.......

Orang Tua/Wali
Wajib melampirkan :
1. Foto Copy Kartu Keluarga
2. Foto Copy Akte Lahir
3. Foto Copy KTP Ayah & Ibu ( ......................................................... )