D.

PENILAIAN HASIL BELAJAR

NILAI
NO Mata Pelajaran Th .............. Th .............. Th .............. Th ..............
Semester
I II III IV V VI VII VIII
Pas Foto
Program Madin Takmiliyah
1 Qur'an 3x4
2 Hadits
3 Tafsir
4 Tajwid
5 Aqidah dan Akhlak
6 Fiqih
7 SKI
8 Bahasa Arab
9 Praktek Ibadah
Jumlah
Program Pelajaran Tambahan
1
2
3
4
5
6
7
8
9
10
Jumlah Nilai
Nilai rata-rata

Kegiatan Ekstra
1
2
3
4
5

Kepribadian
1 Kelakuan
2 Kerajinan
3 Kerapian

E. LAIN - LAIN
23. Piagam Penghargaan
Bidang : .............................. Nomor .............................. Tanggal ..............................
Bidang : .............................. Nomor .............................. Tanggal ..............................
Bidang : .............................. Nomor .............................. Tanggal ..............................

24. Surat Keterangan yang pernah diberikan oleh Madrasah ini

Bidang : .............................. Nomor .............................. Tanggal ..............................
Bidang : .............................. Nomor .............................. Tanggal ..............................
Bidang : .............................. Nomor .............................. Tanggal ..............................

Catata:
1. Diisi dengan huruf balok
2. Program Pelajaran Tambahan diisi sesuai dengan program Madrasah Diniyah
 MADRASAH DINIYAH TAKMILIYAH AWWALIYAH

No Induk : ..................

A. KETERANGAN DIRI SISWA

1. No. Induk : ..............................................................................
2. NISN : ..............................................................................
3. No. Kartu Keluarga/ KK : ..............................................................................
4. Nama Lengkap : ..............................................................................
5. Nama Panggilan : ..............................................................................
6. Tempat Tgl Lahir : ..............................................................................
7. Kebangsaan : ..............................................................................
8. Agama : ..............................................................................
9. Jenis Kelamin : ..............................................................................
10. Alamat Lengkap : ..............................................................................
No. Telp................................................................
B. KETERANGAN KELUARGA
11. Nama Orang Tua : ..............................................................................
a. Ayah : ..............................................................................
b. Ibu : ..............................................................................
12. Alamat Orang Tua : ..............................................................................
..............................................................................
13. Pekerjaan Orang Tua : ..............................................................................
14. Kebangsaan : ..............................................................................
15. Agama : ..............................................................................
16. Nama Wali : ..............................................................................
17. Pekerjaan Wali : ..............................................................................
18. Alamat Wali : ..............................................................................
No. Telp................................................................

C. KETERANGAN PENDIDIKAN
19. Pendidikan Formal : ..............................................................................
20. Pindah : ..............................................................................
a. Asal Madrasah : ..............................................................................
b. Alasan : ..............................................................................
21. Diterima di Madrasah : ..............................................................................
a. Tanggal : ..............................................................................
b. Kelas : ..............................................................................
22. Meninggalkan Madrasah Tahun : ..............................................................................
a. Belum Tamat pada Tingkat : ..............................................................................
b. Sebab Keluar : ..............................................................................
c. Nama Sekolah Tujuan : ..............................................................................
d. Tamat & menerima Ijazah tahun : ..............................................................................
e. Nomor ijazah : ..............................................................................
f. Tanggal dikeluarkan Ijazah : ..............................................................................
g. Melanjutkan ke : ..............................................................................