Buku Induk MTSN 1 Paiton A4
Buku Induk MTSN 1 Paiton A4
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Buku Induk MTSN 1 Paiton A4
Buku Induk MTSN 1 Paiton A4
Diunggah oleh
angel printHak Cipta:
Format Tersedia
Nomor Induk : .................................. Nomor Induk Siswa : ..................................
No Urut
Kelas : ........................................... Kelas : ...........................................
Semester : ........................................... Semester : ...........................................
THN Pelajaran : ........................................... THN Pelajaran : ........................................... 1. Nama Siswa
Mata Pelajaran a. Nama Lengkap : ................................................................
Pengetahuan Pengetahuan Pengetahuan Pengetahuan Pas Photo
(Kl 3) (Kl 3) (Kl 3) (Kl 3) b. Nama Panggilan : ................................................................ Ukuran
2. Jenis Kelamin : Laki Laki / Perempuan ....................... 3x4
Nilai Huruf Nilai Huruf Nilai Huruf Nilai Huruf (1/6)
3. Tempat dan Tanggal Lahir : ................................................................
Kelompok A (Wajib) 4. Agama : ................................................................
5. Kewarganegaraan : WNI / WNI Keturunan
Pendidikan Agama Islam
dan Budi Pekerti 6. Anak Ke : ........................dari.................................
7. Jumlah Saudara : ................................................................ Cap tiga Jari Tangan Kiri
a. Al-Qur’an Hadis Mengenai Pas Foto Bagian
a. Kandung : ................................................................ Bawah Waktu Masuk
b. Aqidah Akhlaq b. Tiri : ................................................................
Tanda Tangan
c. Fikih c. Angkat : ................................................................
8. Anak Yatim/ Yatim Piatu : ................................................................
d. Sejarah Kebudayaan Islam 9. Kegiatan Sehari Hari Di rumah : ................................................................ (..................................)
Pendidikan Pancasila dan
Kewarganegaraan
Bahasa Indonesia 10. Alamat : ...............................................................
: ...............................................................
Bahasa Arab
11. Nomor Telepon : ...............................................................
Matematika 12. Tinggal Dengan Orang Tua/Saudara : ...............................................................
Ilmu Pengetahuan Alam Asrama / Kost : ...............................................................
13. Jarak Tempat Tinggal Ke Sekolah : ...............................................................
Ilmu Pengetahuan Sosial
Pas Photo
Bahasa Inggris Ukuran
Kelompok B (Wajib) 3x4
14. Golongan Darah : ............................................................... (1/6)
Seni Budaya 15. Penyakit Yang Pernah Di derita : ...............................................................
Pendidikan Jasmani, TBC/Cacar/Malaria Dll : ...............................................................
Olah Raga dan Kesehatan 16. Kesehatan Jasmani : ...............................................................
Prakarya dan Kewirausahaan 17. Tinggi Dan Berat Badan : ...............................................................
Cap tiga Jari Tangan Kiri
Mengenai Pas Foto Bagian
Kelompok C ( Muatan Lokal ) KETERANGAN PENDIDIKAN Bawah Waktu Masuk
a. Bahasa Daerah 18. Pendidikan Sebelumnya
Tanda Tangan
a. Lulusan Dari : ...............................................................
b. ...............................................
b. Tangga dan Nomor STTB : ...............................................................
c. ............................................... (..................................)
c. Lama Belajar : ...............................................................
d. ............................................... 19. Pindahan
a. Dari Sekolah / Madrasa : ...............................................................
e. ...............................................
b. Alasan : ...............................................................
Kegiatan Ekstra Kurikuler Keterangan Keterangan 20. Diterima DI sekolah Ini
a. Pramuka a. Di tingkat : ...............................................................
b. Kelompok : ...............................................................
...............................................
c. Jurusan : ...............................................................
............................................... d. Tanggal : ...............................................................
Pas Photo
............................................... Ukuran
KETERANGAN AYAH KANDUNG 3x4
Ketidak Hadiran ........................................................ Hari ........................................................ Hari
21. Nama : ............................................................... (1/6)
Sakit ........................................................ Hari ........................................................ Hari 22. Tempat dan Tanggal Lahir : ...............................................................
Izin ........................................................ Hari ........................................................ Hari 23. Agama : ...............................................................
Tanpa Keterangan ........................................................ Hari ........................................................ Hari 24. Kewarganegaraan : ...............................................................
25. Pendidikan : ............................................................... Cap tiga Jari Tangan Kiri
Keputusan : Berdasarkan Nilai Yang Di peroleh Pada Semester 1 dan 2 maka Wali Kelas 26. Pekerjaan : ............................................................... Mengenai Pas Foto Bagian
siswa ini ditetapkan Bawah Waktu Masuk
27. Penghasilan Per Bulan : ...............................................................
Naik Ke Kelas ..................................(................................................) 28. Alamat Rumah / Nomor Telepon : ............................................................... Tanda Tangan
Tinggal Di Kelas ..................................(................................................)
Tanggal (.........................................) : ...............................................................
..................................(................................................)
29. Masih Hidup / Meninggal Dunia Tahun : ............................................................... (..................................)
KETERANGAN IBU KANDUNG KETERANGAN IBU KANDUNG
30. Nama : ............................................................................................ 30. Nama : ............................................................................................
31 Tempat dan Tanggal Lahir : ............................................................................................ 31 Tempat dan Tanggal Lahir : ............................................................................................
32. Agama : ............................................................................................ 32. Agama : ............................................................................................
33. Kewarganegaraan : ............................................................................................ 33. Kewarganegaraan : ............................................................................................
34. Pendidikan : ............................................................................................ 34. Pendidikan : ............................................................................................
35. Pekerjaan : ............................................................................................ 35. Pekerjaan : ............................................................................................
36. Penghasilan Per Bulan : ............................................................................................ 36. Penghasilan Per Bulan : ............................................................................................
37. Alamat Rumah / Nomor Telepon : ............................................................................................ 37. Alamat Rumah / Nomor Telepon : ............................................................................................
: ............................................................................................ : ............................................................................................
38. Masih Hidup / Meninggal Dunia Tahun : ............................................................................................ 38. Masih Hidup / Meninggal Dunia Tahun : ............................................................................................
39. Nama : ............................................................................................ 39. Nama : ............................................................................................
40. Tempat dan Tanggal Lahir : ............................................................................................ 40. Tempat dan Tanggal Lahir : ............................................................................................
41. Agama : ............................................................................................ 41. Agama : ............................................................................................
42. Kewarganegaraan : ............................................................................................ 42. Kewarganegaraan : ............................................................................................
43. Pendidikan : ............................................................................................ 43. Pendidikan : ............................................................................................
44. Pekerjaan : ............................................................................................ 44. Pekerjaan : ............................................................................................
45. Penghasilan Per Bulan : ............................................................................................ 45. Penghasilan Per Bulan : ............................................................................................
46. Alamat Rumah / Nomor Telepon : ............................................................................................ 46. Alamat Rumah / Nomor Telepon : ............................................................................................
KEGEMARAN SISWA KEGEMARAN SISWA
47. Kesenian : ............................................................................................ 47. Kesenian : ............................................................................................
48. Olah Raga : ............................................................................................ 48. Olah Raga : ............................................................................................
49. Kemasyarakatan / Organisasi : ............................................................................................ 49. Kemasyarakatan / Organisasi : ............................................................................................
50. Lain - Lain : ............................................................................................ 50. Lain - Lain : ............................................................................................
: ............................................................................................ : ............................................................................................
: ............................................................................................ : ............................................................................................
: ............................................................................................ : ............................................................................................
: ............................................................................................ : ............................................................................................
KEGEMARAN PERKEMBANGAN SISWA KEGEMARAN PERKEMBANGAN SISWA
51. Menerima Bea Siswa : Tahun ......................./TK......................dari..................... 51. Menerima Bea Siswa : Tahun ......................./TK......................dari.....................
: Tahun ......................./TK......................dari..................... : Tahun ......................./TK......................dari.....................
: Tahun ......................./TK......................dari..................... : Tahun ......................./TK......................dari.....................
52. Meninggalkan Sekolah : ............................................................................................ 52. Meninggalkan Sekolah : ............................................................................................
a. Tanggal Meninggalkan Sekolah : ............................................................................................ a. Tanggal Meninggalkan Sekolah : ............................................................................................
b. Alasan : ............................................................................................ b. Alasan : ............................................................................................
53. Akhir Pendidikan : ............................................................................................ 53. Akhir Pendidikan : ............................................................................................
a. Tamat Belajar : ............................................................................................ a. Tamat Belajar : ............................................................................................
b. STTB Sekolah : ............................................................................................ b. STTB Sekolah : ............................................................................................
KETERANGAN SETELAH SELESAI PENDIDIKAN KETERANGAN SETELAH SELESAI PENDIDIKAN
54. Melanjutkan di : Tahun ......................./TK......................dari..................... 54. Melanjutkan di : Tahun ......................./TK......................dari.....................
55. Bekerja : Tahun ......................./TK......................dari..................... 55. Bekerja : Tahun ......................./TK......................dari.....................
a. Tanggal Mulai Kerja : Tahun ......................./TK......................dari..................... a. Tanggal Mulai Kerja : Tahun ......................./TK......................dari.....................
b. Nama Perusahaan / Lembaga : ............................................................................................ b. Nama Perusahaan / Lembaga : ............................................................................................
dan lain lain : ............................................................................................ dan lain lain : ............................................................................................
c. Penghasilan : ............................................................................................ c. Penghasilan : ............................................................................................
: ............................................................................................ : ............................................................................................
: ............................................................................................ : ............................................................................................
: ............................................................................................ : ............................................................................................
LAIN - LAIN LAIN - LAIN
Catat Yang Penting : ............................................................................................ Catat Yang Penting : ............................................................................................
..................................................................................................................................................................... .....................................................................................................................................................................
..................................................................................................................................................................... .....................................................................................................................................................................
..................................................................................................................................................................... .....................................................................................................................................................................
..................................................................................................................................................................... .....................................................................................................................................................................
..................................................................................................................................................................... .....................................................................................................................................................................
..................................................................................................................................................................... .....................................................................................................................................................................
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..................................................................................................................................................................... .....................................................................................................................................................................
Nomor Induk Siswa : .................................. No Urut Nomor Induk : ..................................
Kelas : ........................................... Kelas : ...........................................
Semester : ........................................... Semester : ...........................................
1. Nama Siswa THN Pelajaran : ........................................... THN Pelajaran : ...........................................
a. Nama Lengkap : ................................................................ Mata Pelajaran
Pas Photo Pengetahuan Pengetahuan Pengetahuan Pengetahuan
b. Nama Panggilan : ................................................................ Ukuran (Kl 3) (Kl 3) (Kl 3) (Kl 3)
2. Jenis Kelamin : Laki Laki / Perempuan ....................... 3x4
(1/6) Nilai Huruf Nilai Huruf Nilai Huruf Nilai Huruf
3. Tempat dan Tanggal Lahir : ................................................................
4. Agama : ................................................................ Kelompok A (Wajib)
5. Kewarganegaraan : WNI / WNI Keturunan
Pendidikan Agama Islam
6. Anak Ke : ........................dari................................. dan Budi Pekerti
7. Jumlah Saudara : ................................................................ Cap tiga Jari Tangan Kiri
Mengenai Pas Foto Bagian a. Al-Qur’an Hadis
a. Kandung : ................................................................ Bawah Waktu Masuk
b. Tiri : ................................................................ b. Aqidah Akhlaq
Tanda Tangan
c. Angkat : ................................................................ c. Fikih
8. Anak Yatim/ Yatim Piatu : ................................................................
9. Kegiatan Sehari Hari Di rumah : ................................................................ (..................................) d. Sejarah Kebudayaan Islam
Pendidikan Pancasila dan
Kewarganegaraan
10. Alamat : ............................................................... Bahasa Indonesia
: ...............................................................
Bahasa Arab
11. Nomor Telepon : ...............................................................
12. Tinggal Dengan Orang Tua/Saudara : ............................................................... Matematika
Asrama / Kost : ............................................................... Ilmu Pengetahuan Alam
13. Jarak Tempat Tinggal Ke Sekolah : ...............................................................
Ilmu Pengetahuan Sosial
Pas Photo
Ukuran Bahasa Inggris
3x4 Kelompok B (Wajib)
14. Golongan Darah : ............................................................... (1/6)
15. Penyakit Yang Pernah Di derita : ............................................................... Seni Budaya
TBC/Cacar/Malaria Dll : ............................................................... Pendidikan Jasmani,
16. Kesehatan Jasmani : ............................................................... Olah Raga dan Kesehatan
17. Tinggi Dan Berat Badan : ............................................................... Prakarya dan Kewirausahaan
Cap tiga Jari Tangan Kiri
Mengenai Pas Foto Bagian
KETERANGAN PENDIDIKAN Bawah Waktu Masuk
Kelompok C ( Muatan Lokal )
18. Pendidikan Sebelumnya a. Bahasa Daerah
Tanda Tangan
a. Lulusan Dari : ...............................................................
b. ...............................................
b. Tangga dan Nomor STTB : ...............................................................
(..................................) c. ...............................................
c. Lama Belajar : ...............................................................
19. Pindahan d. ...............................................
a. Dari Sekolah / Madrasa : ...............................................................
e. ...............................................
b. Alasan : ...............................................................
20. Diterima DI sekolah Ini Kegiatan Ekstra Kurikuler Keterangan Keterangan
a. Di tingkat : ............................................................... a. Pramuka
b. Kelompok : ...............................................................
...............................................
c. Jurusan : ...............................................................
d. Tanggal : ............................................................... ...............................................
Pas Photo
Ukuran ...............................................
KETERANGAN AYAH KANDUNG 3x4 Ketidak Hadiran ........................................................ Hari ........................................................ Hari
21. Nama : ............................................................... (1/6)
22. Tempat dan Tanggal Lahir : ............................................................... Sakit ........................................................ Hari ........................................................ Hari
23. Agama : ............................................................... Izin ........................................................ Hari ........................................................ Hari
24. Kewarganegaraan : ............................................................... Tanpa Keterangan ........................................................ Hari ........................................................ Hari
25. Pendidikan : ............................................................... Cap tiga Jari Tangan Kiri
26. Pekerjaan : ............................................................... Mengenai Pas Foto Bagian Keputusan : Berdasarkan Nilai Yang Di peroleh Pada Semester 1 dan 2 maka Wali Kelas
Bawah Waktu Masuk siswa ini ditetapkan
27. Penghasilan Per Bulan : ...............................................................
28. Alamat Rumah / Nomor Telepon : ............................................................... Naik Ke Kelas ..................................(................................................)
Tanda Tangan
Tinggal Di Kelas ..................................(................................................)
: ............................................................... Tanggal (.........................................)
..................................(................................................)
29. Masih Hidup / Meninggal Dunia Tahun : ............................................................... (..................................)
Nomor Induk : .................................. Nomor Induk Siswa : .................................. No Urut
Kelas : ........................................... Kelas : ...........................................
Semester : ........................................... Semester : ...........................................
THN Pelajaran : ........................................... THN Pelajaran : ........................................... 1. Nama Siswa
Mata Pelajaran a. Nama Lengkap : ................................................................
Pengetahuan Pengetahuan Pengetahuan Pengetahuan Pas Photo
(Kl 3) (Kl 3) (Kl 3) (Kl 3) b. Nama Panggilan : ................................................................ Ukuran
2. Jenis Kelamin : Laki Laki / Perempuan ....................... 3x4
Nilai Huruf Nilai Huruf Nilai Huruf Nilai Huruf (1/6)
3. Tempat dan Tanggal Lahir : ................................................................
Kelompok A (Wajib) 4. Agama : ................................................................
5. Kewarganegaraan : WNI / WNI Keturunan
Pendidikan Agama Islam
dan Budi Pekerti 6. Anak Ke : ........................dari.................................
7. Jumlah Saudara : ................................................................ Cap tiga Jari Tangan Kiri
a. Al-Qur’an Hadis Mengenai Pas Foto Bagian
a. Kandung : ................................................................ Bawah Waktu Masuk
b. Aqidah Akhlaq b. Tiri : ................................................................
Tanda Tangan
c. Fikih c. Angkat : ................................................................
8. Anak Yatim/ Yatim Piatu : ................................................................
d. Sejarah Kebudayaan Islam 9. Kegiatan Sehari Hari Di rumah : ................................................................ (..................................)
Pendidikan Pancasila dan
Kewarganegaraan
Bahasa Indonesia 10. Alamat : ...............................................................
: ...............................................................
Bahasa Arab
11. Nomor Telepon : ...............................................................
Matematika 12. Tinggal Dengan Orang Tua/Saudara : ...............................................................
Ilmu Pengetahuan Alam Asrama / Kost : ...............................................................
13. Jarak Tempat Tinggal Ke Sekolah : ...............................................................
Ilmu Pengetahuan Sosial
Pas Photo
Bahasa Inggris Ukuran
Kelompok B (Wajib) 3x4
14. Golongan Darah : ............................................................... (1/6)
Seni Budaya 15. Penyakit Yang Pernah Di derita : ...............................................................
Pendidikan Jasmani, TBC/Cacar/Malaria Dll : ...............................................................
Olah Raga dan Kesehatan 16. Kesehatan Jasmani : ...............................................................
Prakarya dan Kewirausahaan 17. Tinggi Dan Berat Badan : ...............................................................
Cap tiga Jari Tangan Kiri
Mengenai Pas Foto Bagian
Kelompok C ( Muatan Lokal ) KETERANGAN PENDIDIKAN Bawah Waktu Masuk
a. Bahasa Daerah 18. Pendidikan Sebelumnya
Tanda Tangan
a. Lulusan Dari : ...............................................................
b. ...............................................
b. Tangga dan Nomor STTB : ...............................................................
c. ............................................... (..................................)
c. Lama Belajar : ...............................................................
d. ............................................... 19. Pindahan
a. Dari Sekolah / Madrasa : ...............................................................
e. ...............................................
b. Alasan : ...............................................................
Kegiatan Ekstra Kurikuler Keterangan Keterangan 20. Diterima DI sekolah Ini
a. Pramuka a. Di tingkat : ...............................................................
b. Kelompok : ...............................................................
...............................................
c. Jurusan : ...............................................................
............................................... d. Tanggal : ...............................................................
Pas Photo
............................................... Ukuran
KETERANGAN AYAH KANDUNG 3x4
Ketidak Hadiran ........................................................ Hari ........................................................ Hari
21. Nama : ............................................................... (1/6)
Sakit ........................................................ Hari ........................................................ Hari 22. Tempat dan Tanggal Lahir : ...............................................................
Izin ........................................................ Hari ........................................................ Hari 23. Agama : ...............................................................
Tanpa Keterangan ........................................................ Hari ........................................................ Hari 24. Kewarganegaraan : ...............................................................
25. Pendidikan : ............................................................... Cap tiga Jari Tangan Kiri
Keputusan : Berdasarkan Nilai Yang Di peroleh Pada Semester 1 dan 2 maka Wali Kelas 26. Pekerjaan : ............................................................... Mengenai Pas Foto Bagian
siswa ini ditetapkan Bawah Waktu Masuk
27. Penghasilan Per Bulan : ...............................................................
Naik Ke Kelas ..................................(................................................) 28. Alamat Rumah / Nomor Telepon : ............................................................... Tanda Tangan
Tinggal Di Kelas ..................................(................................................)
Tanggal (.........................................) : ...............................................................
..................................(................................................)
29. Masih Hidup / Meninggal Dunia Tahun : ............................................................... (..................................)
KETERANGAN IBU KANDUNG KETERANGAN IBU KANDUNG
30. Nama : ............................................................................................ 30. Nama : ............................................................................................
31 Tempat dan Tanggal Lahir : ............................................................................................ 31 Tempat dan Tanggal Lahir : ............................................................................................
32. Agama : ............................................................................................ 32. Agama : ............................................................................................
33. Kewarganegaraan : ............................................................................................ 33. Kewarganegaraan : ............................................................................................
34. Pendidikan : ............................................................................................ 34. Pendidikan : ............................................................................................
35. Pekerjaan : ............................................................................................ 35. Pekerjaan : ............................................................................................
36. Penghasilan Per Bulan : ............................................................................................ 36. Penghasilan Per Bulan : ............................................................................................
37. Alamat Rumah / Nomor Telepon : ............................................................................................ 37. Alamat Rumah / Nomor Telepon : ............................................................................................
: ............................................................................................ : ............................................................................................
38. Masih Hidup / Meninggal Dunia Tahun : ............................................................................................ 38. Masih Hidup / Meninggal Dunia Tahun : ............................................................................................
39. Nama : ............................................................................................ 39. Nama : ............................................................................................
40. Tempat dan Tanggal Lahir : ............................................................................................ 40. Tempat dan Tanggal Lahir : ............................................................................................
41. Agama : ............................................................................................ 41. Agama : ............................................................................................
42. Kewarganegaraan : ............................................................................................ 42. Kewarganegaraan : ............................................................................................
43. Pendidikan : ............................................................................................ 43. Pendidikan : ............................................................................................
44. Pekerjaan : ............................................................................................ 44. Pekerjaan : ............................................................................................
45. Penghasilan Per Bulan : ............................................................................................ 45. Penghasilan Per Bulan : ............................................................................................
46. Alamat Rumah / Nomor Telepon : ............................................................................................ 46. Alamat Rumah / Nomor Telepon : ............................................................................................
KEGEMARAN SISWA KEGEMARAN SISWA
47. Kesenian : ............................................................................................ 47. Kesenian : ............................................................................................
48. Olah Raga : ............................................................................................ 48. Olah Raga : ............................................................................................
49. Kemasyarakatan / Organisasi : ............................................................................................ 49. Kemasyarakatan / Organisasi : ............................................................................................
50. Lain - Lain : ............................................................................................ 50. Lain - Lain : ............................................................................................
: ............................................................................................ : ............................................................................................
: ............................................................................................ : ............................................................................................
: ............................................................................................ : ............................................................................................
: ............................................................................................ : ............................................................................................
KEGEMARAN PERKEMBANGAN SISWA KEGEMARAN PERKEMBANGAN SISWA
51. Menerima Bea Siswa : Tahun ......................./TK......................dari..................... 51. Menerima Bea Siswa : Tahun ......................./TK......................dari.....................
: Tahun ......................./TK......................dari..................... : Tahun ......................./TK......................dari.....................
: Tahun ......................./TK......................dari..................... : Tahun ......................./TK......................dari.....................
52. Meninggalkan Sekolah : ............................................................................................ 52. Meninggalkan Sekolah : ............................................................................................
a. Tanggal Meninggalkan Sekolah : ............................................................................................ a. Tanggal Meninggalkan Sekolah : ............................................................................................
b. Alasan : ............................................................................................ b. Alasan : ............................................................................................
53. Akhir Pendidikan : ............................................................................................ 53. Akhir Pendidikan : ............................................................................................
a. Tamat Belajar : ............................................................................................ a. Tamat Belajar : ............................................................................................
b. STTB Sekolah : ............................................................................................ b. STTB Sekolah : ............................................................................................
KETERANGAN SETELAH SELESAI PENDIDIKAN KETERANGAN SETELAH SELESAI PENDIDIKAN
54. Melanjutkan di : Tahun ......................./TK......................dari..................... 54. Melanjutkan di : Tahun ......................./TK......................dari.....................
55. Bekerja : Tahun ......................./TK......................dari..................... 55. Bekerja : Tahun ......................./TK......................dari.....................
a. Tanggal Mulai Kerja : Tahun ......................./TK......................dari..................... a. Tanggal Mulai Kerja : Tahun ......................./TK......................dari.....................
b. Nama Perusahaan / Lembaga : ............................................................................................ b. Nama Perusahaan / Lembaga : ............................................................................................
dan lain lain : ............................................................................................ dan lain lain : ............................................................................................
c. Penghasilan : ............................................................................................ c. Penghasilan : ............................................................................................
: ............................................................................................ : ............................................................................................
: ............................................................................................ : ............................................................................................
: ............................................................................................ : ............................................................................................
LAIN - LAIN LAIN - LAIN
Catat Yang Penting : ............................................................................................ Catat Yang Penting : ............................................................................................
..................................................................................................................................................................... .....................................................................................................................................................................
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..................................................................................................................................................................... .....................................................................................................................................................................
Nomor Induk Siswa : .................................. No Urut Nomor Induk : ..................................
Kelas : ........................................... Kelas : ...........................................
Semester : ........................................... Semester : ...........................................
1. Nama Siswa THN Pelajaran : ........................................... THN Pelajaran : ...........................................
a. Nama Lengkap : ................................................................ Mata Pelajaran
Pas Photo Pengetahuan Pengetahuan Pengetahuan Pengetahuan
b. Nama Panggilan : ................................................................ Ukuran (Kl 3) (Kl 3) (Kl 3) (Kl 3)
2. Jenis Kelamin : Laki Laki / Perempuan ....................... 3x4
(1/6) Nilai Huruf Nilai Huruf Nilai Huruf Nilai Huruf
3. Tempat dan Tanggal Lahir : ................................................................
4. Agama : ................................................................ Kelompok A (Wajib)
5. Kewarganegaraan : WNI / WNI Keturunan
Pendidikan Agama Islam
6. Anak Ke : ........................dari................................. dan Budi Pekerti
7. Jumlah Saudara : ................................................................ Cap tiga Jari Tangan Kiri
Mengenai Pas Foto Bagian a. Al-Qur’an Hadis
a. Kandung : ................................................................ Bawah Waktu Masuk
b. Tiri : ................................................................ b. Aqidah Akhlaq
Tanda Tangan
c. Angkat : ................................................................ c. Fikih
8. Anak Yatim/ Yatim Piatu : ................................................................
9. Kegiatan Sehari Hari Di rumah : ................................................................ (..................................) d. Sejarah Kebudayaan Islam
Pendidikan Pancasila dan
Kewarganegaraan
10. Alamat : ............................................................... Bahasa Indonesia
: ...............................................................
Bahasa Arab
11. Nomor Telepon : ...............................................................
12. Tinggal Dengan Orang Tua/Saudara : ............................................................... Matematika
Asrama / Kost : ............................................................... Ilmu Pengetahuan Alam
13. Jarak Tempat Tinggal Ke Sekolah : ...............................................................
Ilmu Pengetahuan Sosial
Pas Photo
Ukuran Bahasa Inggris
3x4 Kelompok B (Wajib)
14. Golongan Darah : ............................................................... (1/6)
15. Penyakit Yang Pernah Di derita : ............................................................... Seni Budaya
TBC/Cacar/Malaria Dll : ............................................................... Pendidikan Jasmani,
16. Kesehatan Jasmani : ............................................................... Olah Raga dan Kesehatan
17. Tinggi Dan Berat Badan : ............................................................... Prakarya dan Kewirausahaan
Cap tiga Jari Tangan Kiri
Mengenai Pas Foto Bagian
KETERANGAN PENDIDIKAN Bawah Waktu Masuk
Kelompok C ( Muatan Lokal )
18. Pendidikan Sebelumnya a. Bahasa Daerah
Tanda Tangan
a. Lulusan Dari : ...............................................................
b. ...............................................
b. Tangga dan Nomor STTB : ...............................................................
(..................................) c. ...............................................
c. Lama Belajar : ...............................................................
19. Pindahan d. ...............................................
a. Dari Sekolah / Madrasa : ...............................................................
e. ...............................................
b. Alasan : ...............................................................
20. Diterima DI sekolah Ini Kegiatan Ekstra Kurikuler Keterangan Keterangan
a. Di tingkat : ............................................................... a. Pramuka
b. Kelompok : ...............................................................
...............................................
c. Jurusan : ...............................................................
d. Tanggal : ............................................................... ...............................................
Pas Photo
Ukuran ...............................................
KETERANGAN AYAH KANDUNG 3x4 Ketidak Hadiran ........................................................ Hari ........................................................ Hari
21. Nama : ............................................................... (1/6)
22. Tempat dan Tanggal Lahir : ............................................................... Sakit ........................................................ Hari ........................................................ Hari
23. Agama : ............................................................... Izin ........................................................ Hari ........................................................ Hari
24. Kewarganegaraan : ............................................................... Tanpa Keterangan ........................................................ Hari ........................................................ Hari
25. Pendidikan : ............................................................... Cap tiga Jari Tangan Kiri
26. Pekerjaan : ............................................................... Mengenai Pas Foto Bagian Keputusan : Berdasarkan Nilai Yang Di peroleh Pada Semester 1 dan 2 maka Wali Kelas
Bawah Waktu Masuk siswa ini ditetapkan
27. Penghasilan Per Bulan : ...............................................................
28. Alamat Rumah / Nomor Telepon : ............................................................... Naik Ke Kelas ..................................(................................................)
Tanda Tangan
Tinggal Di Kelas ..................................(................................................)
: ............................................................... Tanggal (.........................................)
..................................(................................................)
29. Masih Hidup / Meninggal Dunia Tahun : ............................................................... (..................................)
Nomor Induk : .................................. Nomor Induk Siswa : .................................. No Urut
Kelas : ........................................... Kelas : ...........................................
Semester : ........................................... Semester : ...........................................
THN Pelajaran : ........................................... THN Pelajaran : ........................................... 1. Nama Siswa
Mata Pelajaran a. Nama Lengkap : ................................................................
Pengetahuan Pengetahuan Pengetahuan Pengetahuan Pas Photo
(Kl 3) (Kl 3) (Kl 3) (Kl 3) b. Nama Panggilan : ................................................................ Ukuran
2. Jenis Kelamin : Laki Laki / Perempuan ....................... 3x4
Nilai Huruf Nilai Huruf Nilai Huruf Nilai Huruf (1/6)
3. Tempat dan Tanggal Lahir : ................................................................
Kelompok A (Wajib) 4. Agama : ................................................................
5. Kewarganegaraan : WNI / WNI Keturunan
Pendidikan Agama Islam
dan Budi Pekerti 6. Anak Ke : ........................dari.................................
7. Jumlah Saudara : ................................................................ Cap tiga Jari Tangan Kiri
a. Al-Qur’an Hadis Mengenai Pas Foto Bagian
a. Kandung : ................................................................ Bawah Waktu Masuk
b. Aqidah Akhlaq b. Tiri : ................................................................
Tanda Tangan
c. Fikih c. Angkat : ................................................................
8. Anak Yatim/ Yatim Piatu : ................................................................
d. Sejarah Kebudayaan Islam 9. Kegiatan Sehari Hari Di rumah : ................................................................ (..................................)
Pendidikan Pancasila dan
Kewarganegaraan
Bahasa Indonesia 10. Alamat : ...............................................................
: ...............................................................
Bahasa Arab
11. Nomor Telepon : ...............................................................
Matematika 12. Tinggal Dengan Orang Tua/Saudara : ...............................................................
Ilmu Pengetahuan Alam Asrama / Kost : ...............................................................
13. Jarak Tempat Tinggal Ke Sekolah : ...............................................................
Ilmu Pengetahuan Sosial
Pas Photo
Bahasa Inggris Ukuran
Kelompok B (Wajib) 3x4
14. Golongan Darah : ............................................................... (1/6)
Seni Budaya 15. Penyakit Yang Pernah Di derita : ...............................................................
Pendidikan Jasmani, TBC/Cacar/Malaria Dll : ...............................................................
Olah Raga dan Kesehatan 16. Kesehatan Jasmani : ...............................................................
Prakarya dan Kewirausahaan 17. Tinggi Dan Berat Badan : ...............................................................
Cap tiga Jari Tangan Kiri
Mengenai Pas Foto Bagian
Kelompok C ( Muatan Lokal ) KETERANGAN PENDIDIKAN Bawah Waktu Masuk
a. Bahasa Daerah 18. Pendidikan Sebelumnya
Tanda Tangan
a. Lulusan Dari : ...............................................................
b. ...............................................
b. Tangga dan Nomor STTB : ...............................................................
c. ............................................... (..................................)
c. Lama Belajar : ...............................................................
d. ............................................... 19. Pindahan
a. Dari Sekolah / Madrasa : ...............................................................
e. ...............................................
b. Alasan : ...............................................................
Kegiatan Ekstra Kurikuler Keterangan Keterangan 20. Diterima DI sekolah Ini
a. Pramuka a. Di tingkat : ...............................................................
b. Kelompok : ...............................................................
...............................................
c. Jurusan : ...............................................................
............................................... d. Tanggal : ...............................................................
Pas Photo
............................................... Ukuran
KETERANGAN AYAH KANDUNG 3x4
Ketidak Hadiran ........................................................ Hari ........................................................ Hari
21. Nama : ............................................................... (1/6)
Sakit ........................................................ Hari ........................................................ Hari 22. Tempat dan Tanggal Lahir : ...............................................................
Izin ........................................................ Hari ........................................................ Hari 23. Agama : ...............................................................
Tanpa Keterangan ........................................................ Hari ........................................................ Hari 24. Kewarganegaraan : ...............................................................
25. Pendidikan : ............................................................... Cap tiga Jari Tangan Kiri
Keputusan : Berdasarkan Nilai Yang Di peroleh Pada Semester 1 dan 2 maka Wali Kelas 26. Pekerjaan : ............................................................... Mengenai Pas Foto Bagian
siswa ini ditetapkan Bawah Waktu Masuk
27. Penghasilan Per Bulan : ...............................................................
Naik Ke Kelas ..................................(................................................) 28. Alamat Rumah / Nomor Telepon : ............................................................... Tanda Tangan
Tinggal Di Kelas ..................................(................................................)
Tanggal (.........................................) : ...............................................................
..................................(................................................)
29. Masih Hidup / Meninggal Dunia Tahun : ............................................................... (..................................)
KETERANGAN IBU KANDUNG KETERANGAN IBU KANDUNG
30. Nama : ............................................................................................ 30. Nama : ............................................................................................
31 Tempat dan Tanggal Lahir : ............................................................................................ 31 Tempat dan Tanggal Lahir : ............................................................................................
32. Agama : ............................................................................................ 32. Agama : ............................................................................................
33. Kewarganegaraan : ............................................................................................ 33. Kewarganegaraan : ............................................................................................
34. Pendidikan : ............................................................................................ 34. Pendidikan : ............................................................................................
35. Pekerjaan : ............................................................................................ 35. Pekerjaan : ............................................................................................
36. Penghasilan Per Bulan : ............................................................................................ 36. Penghasilan Per Bulan : ............................................................................................
37. Alamat Rumah / Nomor Telepon : ............................................................................................ 37. Alamat Rumah / Nomor Telepon : ............................................................................................
: ............................................................................................ : ............................................................................................
38. Masih Hidup / Meninggal Dunia Tahun : ............................................................................................ 38. Masih Hidup / Meninggal Dunia Tahun : ............................................................................................
39. Nama : ............................................................................................ 39. Nama : ............................................................................................
40. Tempat dan Tanggal Lahir : ............................................................................................ 40. Tempat dan Tanggal Lahir : ............................................................................................
41. Agama : ............................................................................................ 41. Agama : ............................................................................................
42. Kewarganegaraan : ............................................................................................ 42. Kewarganegaraan : ............................................................................................
43. Pendidikan : ............................................................................................ 43. Pendidikan : ............................................................................................
44. Pekerjaan : ............................................................................................ 44. Pekerjaan : ............................................................................................
45. Penghasilan Per Bulan : ............................................................................................ 45. Penghasilan Per Bulan : ............................................................................................
46. Alamat Rumah / Nomor Telepon : ............................................................................................ 46. Alamat Rumah / Nomor Telepon : ............................................................................................
KEGEMARAN SISWA KEGEMARAN SISWA
47. Kesenian : ............................................................................................ 47. Kesenian : ............................................................................................
48. Olah Raga : ............................................................................................ 48. Olah Raga : ............................................................................................
49. Kemasyarakatan / Organisasi : ............................................................................................ 49. Kemasyarakatan / Organisasi : ............................................................................................
50. Lain - Lain : ............................................................................................ 50. Lain - Lain : ............................................................................................
: ............................................................................................ : ............................................................................................
: ............................................................................................ : ............................................................................................
: ............................................................................................ : ............................................................................................
: ............................................................................................ : ............................................................................................
KEGEMARAN PERKEMBANGAN SISWA KEGEMARAN PERKEMBANGAN SISWA
51. Menerima Bea Siswa : Tahun ......................./TK......................dari..................... 51. Menerima Bea Siswa : Tahun ......................./TK......................dari.....................
: Tahun ......................./TK......................dari..................... : Tahun ......................./TK......................dari.....................
: Tahun ......................./TK......................dari..................... : Tahun ......................./TK......................dari.....................
52. Meninggalkan Sekolah : ............................................................................................ 52. Meninggalkan Sekolah : ............................................................................................
a. Tanggal Meninggalkan Sekolah : ............................................................................................ a. Tanggal Meninggalkan Sekolah : ............................................................................................
b. Alasan : ............................................................................................ b. Alasan : ............................................................................................
53. Akhir Pendidikan : ............................................................................................ 53. Akhir Pendidikan : ............................................................................................
a. Tamat Belajar : ............................................................................................ a. Tamat Belajar : ............................................................................................
b. STTB Sekolah : ............................................................................................ b. STTB Sekolah : ............................................................................................
KETERANGAN SETELAH SELESAI PENDIDIKAN KETERANGAN SETELAH SELESAI PENDIDIKAN
54. Melanjutkan di : Tahun ......................./TK......................dari..................... 54. Melanjutkan di : Tahun ......................./TK......................dari.....................
55. Bekerja : Tahun ......................./TK......................dari..................... 55. Bekerja : Tahun ......................./TK......................dari.....................
a. Tanggal Mulai Kerja : Tahun ......................./TK......................dari..................... a. Tanggal Mulai Kerja : Tahun ......................./TK......................dari.....................
b. Nama Perusahaan / Lembaga : ............................................................................................ b. Nama Perusahaan / Lembaga : ............................................................................................
dan lain lain : ............................................................................................ dan lain lain : ............................................................................................
c. Penghasilan : ............................................................................................ c. Penghasilan : ............................................................................................
: ............................................................................................ : ............................................................................................
: ............................................................................................ : ............................................................................................
: ............................................................................................ : ............................................................................................
LAIN - LAIN LAIN - LAIN
Catat Yang Penting : ............................................................................................ Catat Yang Penting : ............................................................................................
..................................................................................................................................................................... .....................................................................................................................................................................
..................................................................................................................................................................... .....................................................................................................................................................................
..................................................................................................................................................................... .....................................................................................................................................................................
..................................................................................................................................................................... .....................................................................................................................................................................
..................................................................................................................................................................... .....................................................................................................................................................................
..................................................................................................................................................................... .....................................................................................................................................................................
..................................................................................................................................................................... .....................................................................................................................................................................
..................................................................................................................................................................... .....................................................................................................................................................................
Nomor Induk Siswa : .................................. No Urut Nomor Induk : ..................................
Kelas : ........................................... Kelas : ...........................................
Semester : ........................................... Semester : ...........................................
1. Nama Siswa THN Pelajaran : ........................................... THN Pelajaran : ...........................................
a. Nama Lengkap : ................................................................ Mata Pelajaran
Pas Photo Pengetahuan Pengetahuan Pengetahuan Pengetahuan
b. Nama Panggilan : ................................................................ Ukuran (Kl 3) (Kl 3) (Kl 3) (Kl 3)
2. Jenis Kelamin : Laki Laki / Perempuan ....................... 3x4
(1/6) Nilai Huruf Nilai Huruf Nilai Huruf Nilai Huruf
3. Tempat dan Tanggal Lahir : ................................................................
4. Agama : ................................................................ Kelompok A (Wajib)
5. Kewarganegaraan : WNI / WNI Keturunan
Pendidikan Agama Islam
6. Anak Ke : ........................dari................................. dan Budi Pekerti
7. Jumlah Saudara : ................................................................ Cap tiga Jari Tangan Kiri
Mengenai Pas Foto Bagian a. Al-Qur’an Hadis
a. Kandung : ................................................................ Bawah Waktu Masuk
b. Tiri : ................................................................ b. Aqidah Akhlaq
Tanda Tangan
c. Angkat : ................................................................ c. Fikih
8. Anak Yatim/ Yatim Piatu : ................................................................
9. Kegiatan Sehari Hari Di rumah : ................................................................ (..................................) d. Sejarah Kebudayaan Islam
Pendidikan Pancasila dan
Kewarganegaraan
10. Alamat : ............................................................... Bahasa Indonesia
: ...............................................................
Bahasa Arab
11. Nomor Telepon : ...............................................................
12. Tinggal Dengan Orang Tua/Saudara : ............................................................... Matematika
Asrama / Kost : ............................................................... Ilmu Pengetahuan Alam
13. Jarak Tempat Tinggal Ke Sekolah : ...............................................................
Ilmu Pengetahuan Sosial
Pas Photo
Ukuran Bahasa Inggris
3x4 Kelompok B (Wajib)
14. Golongan Darah : ............................................................... (1/6)
15. Penyakit Yang Pernah Di derita : ............................................................... Seni Budaya
TBC/Cacar/Malaria Dll : ............................................................... Pendidikan Jasmani,
16. Kesehatan Jasmani : ............................................................... Olah Raga dan Kesehatan
17. Tinggi Dan Berat Badan : ............................................................... Prakarya dan Kewirausahaan
Cap tiga Jari Tangan Kiri
Mengenai Pas Foto Bagian
KETERANGAN PENDIDIKAN Bawah Waktu Masuk
Kelompok C ( Muatan Lokal )
18. Pendidikan Sebelumnya a. Bahasa Daerah
Tanda Tangan
a. Lulusan Dari : ...............................................................
b. ...............................................
b. Tangga dan Nomor STTB : ...............................................................
(..................................) c. ...............................................
c. Lama Belajar : ...............................................................
19. Pindahan d. ...............................................
a. Dari Sekolah / Madrasa : ...............................................................
e. ...............................................
b. Alasan : ...............................................................
20. Diterima DI sekolah Ini Kegiatan Ekstra Kurikuler Keterangan Keterangan
a. Di tingkat : ............................................................... a. Pramuka
b. Kelompok : ...............................................................
...............................................
c. Jurusan : ...............................................................
d. Tanggal : ............................................................... ...............................................
Pas Photo
Ukuran ...............................................
KETERANGAN AYAH KANDUNG 3x4 Ketidak Hadiran ........................................................ Hari ........................................................ Hari
21. Nama : ............................................................... (1/6)
22. Tempat dan Tanggal Lahir : ............................................................... Sakit ........................................................ Hari ........................................................ Hari
23. Agama : ............................................................... Izin ........................................................ Hari ........................................................ Hari
24. Kewarganegaraan : ............................................................... Tanpa Keterangan ........................................................ Hari ........................................................ Hari
25. Pendidikan : ............................................................... Cap tiga Jari Tangan Kiri
26. Pekerjaan : ............................................................... Mengenai Pas Foto Bagian Keputusan : Berdasarkan Nilai Yang Di peroleh Pada Semester 1 dan 2 maka Wali Kelas
Bawah Waktu Masuk siswa ini ditetapkan
27. Penghasilan Per Bulan : ...............................................................
28. Alamat Rumah / Nomor Telepon : ............................................................... Naik Ke Kelas ..................................(................................................)
Tanda Tangan
Tinggal Di Kelas ..................................(................................................)
: ............................................................... Tanggal (.........................................)
..................................(................................................)
29. Masih Hidup / Meninggal Dunia Tahun : ............................................................... (..................................)
Nomor Induk : .................................. Nomor Induk Siswa : .................................. No Urut
Kelas : ........................................... Kelas : ...........................................
Semester : ........................................... Semester : ...........................................
THN Pelajaran : ........................................... THN Pelajaran : ........................................... 1. Nama Siswa
Mata Pelajaran a. Nama Lengkap : ................................................................
Pengetahuan Pengetahuan Pengetahuan Pengetahuan Pas Photo
(Kl 3) (Kl 3) (Kl 3) (Kl 3) b. Nama Panggilan : ................................................................ Ukuran
2. Jenis Kelamin : Laki Laki / Perempuan ....................... 3x4
Nilai Huruf Nilai Huruf Nilai Huruf Nilai Huruf (1/6)
3. Tempat dan Tanggal Lahir : ................................................................
Kelompok A (Wajib) 4. Agama : ................................................................
5. Kewarganegaraan : WNI / WNI Keturunan
Pendidikan Agama Islam
dan Budi Pekerti 6. Anak Ke : ........................dari.................................
7. Jumlah Saudara : ................................................................ Cap tiga Jari Tangan Kiri
a. Al-Qur’an Hadis Mengenai Pas Foto Bagian
a. Kandung : ................................................................ Bawah Waktu Masuk
b. Aqidah Akhlaq b. Tiri : ................................................................
Tanda Tangan
c. Fikih c. Angkat : ................................................................
8. Anak Yatim/ Yatim Piatu : ................................................................
d. Sejarah Kebudayaan Islam 9. Kegiatan Sehari Hari Di rumah : ................................................................ (..................................)
Pendidikan Pancasila dan
Kewarganegaraan
Bahasa Indonesia 10. Alamat : ...............................................................
: ...............................................................
Bahasa Arab
11. Nomor Telepon : ...............................................................
Matematika 12. Tinggal Dengan Orang Tua/Saudara : ...............................................................
Ilmu Pengetahuan Alam Asrama / Kost : ...............................................................
13. Jarak Tempat Tinggal Ke Sekolah : ...............................................................
Ilmu Pengetahuan Sosial
Pas Photo
Bahasa Inggris Ukuran
Kelompok B (Wajib) 3x4
14. Golongan Darah : ............................................................... (1/6)
Seni Budaya 15. Penyakit Yang Pernah Di derita : ...............................................................
Pendidikan Jasmani, TBC/Cacar/Malaria Dll : ...............................................................
Olah Raga dan Kesehatan 16. Kesehatan Jasmani : ...............................................................
Prakarya dan Kewirausahaan 17. Tinggi Dan Berat Badan : ...............................................................
Cap tiga Jari Tangan Kiri
Mengenai Pas Foto Bagian
Kelompok C ( Muatan Lokal ) KETERANGAN PENDIDIKAN Bawah Waktu Masuk
a. Bahasa Daerah 18. Pendidikan Sebelumnya
Tanda Tangan
a. Lulusan Dari : ...............................................................
b. ...............................................
b. Tangga dan Nomor STTB : ...............................................................
c. ............................................... (..................................)
c. Lama Belajar : ...............................................................
d. ............................................... 19. Pindahan
a. Dari Sekolah / Madrasa : ...............................................................
e. ...............................................
b. Alasan : ...............................................................
Kegiatan Ekstra Kurikuler Keterangan Keterangan 20. Diterima DI sekolah Ini
a. Pramuka a. Di tingkat : ...............................................................
b. Kelompok : ...............................................................
...............................................
c. Jurusan : ...............................................................
............................................... d. Tanggal : ...............................................................
Pas Photo
............................................... Ukuran
KETERANGAN AYAH KANDUNG 3x4
Ketidak Hadiran ........................................................ Hari ........................................................ Hari
21. Nama : ............................................................... (1/6)
Sakit ........................................................ Hari ........................................................ Hari 22. Tempat dan Tanggal Lahir : ...............................................................
Izin ........................................................ Hari ........................................................ Hari 23. Agama : ...............................................................
Tanpa Keterangan ........................................................ Hari ........................................................ Hari 24. Kewarganegaraan : ...............................................................
25. Pendidikan : ............................................................... Cap tiga Jari Tangan Kiri
Keputusan : Berdasarkan Nilai Yang Di peroleh Pada Semester 1 dan 2 maka Wali Kelas 26. Pekerjaan : ............................................................... Mengenai Pas Foto Bagian
siswa ini ditetapkan Bawah Waktu Masuk
27. Penghasilan Per Bulan : ...............................................................
Naik Ke Kelas ..................................(................................................) 28. Alamat Rumah / Nomor Telepon : ............................................................... Tanda Tangan
Tinggal Di Kelas ..................................(................................................)
Tanggal (.........................................) : ...............................................................
..................................(................................................)
29. Masih Hidup / Meninggal Dunia Tahun : ............................................................... (..................................)
KETERANGAN IBU KANDUNG KETERANGAN IBU KANDUNG
30. Nama : ............................................................................................ 30. Nama : ............................................................................................
31 Tempat dan Tanggal Lahir : ............................................................................................ 31 Tempat dan Tanggal Lahir : ............................................................................................
32. Agama : ............................................................................................ 32. Agama : ............................................................................................
33. Kewarganegaraan : ............................................................................................ 33. Kewarganegaraan : ............................................................................................
34. Pendidikan : ............................................................................................ 34. Pendidikan : ............................................................................................
35. Pekerjaan : ............................................................................................ 35. Pekerjaan : ............................................................................................
36. Penghasilan Per Bulan : ............................................................................................ 36. Penghasilan Per Bulan : ............................................................................................
37. Alamat Rumah / Nomor Telepon : ............................................................................................ 37. Alamat Rumah / Nomor Telepon : ............................................................................................
: ............................................................................................ : ............................................................................................
38. Masih Hidup / Meninggal Dunia Tahun : ............................................................................................ 38. Masih Hidup / Meninggal Dunia Tahun : ............................................................................................
39. Nama : ............................................................................................ 39. Nama : ............................................................................................
40. Tempat dan Tanggal Lahir : ............................................................................................ 40. Tempat dan Tanggal Lahir : ............................................................................................
41. Agama : ............................................................................................ 41. Agama : ............................................................................................
42. Kewarganegaraan : ............................................................................................ 42. Kewarganegaraan : ............................................................................................
43. Pendidikan : ............................................................................................ 43. Pendidikan : ............................................................................................
44. Pekerjaan : ............................................................................................ 44. Pekerjaan : ............................................................................................
45. Penghasilan Per Bulan : ............................................................................................ 45. Penghasilan Per Bulan : ............................................................................................
46. Alamat Rumah / Nomor Telepon : ............................................................................................ 46. Alamat Rumah / Nomor Telepon : ............................................................................................
KEGEMARAN SISWA KEGEMARAN SISWA
47. Kesenian : ............................................................................................ 47. Kesenian : ............................................................................................
48. Olah Raga : ............................................................................................ 48. Olah Raga : ............................................................................................
49. Kemasyarakatan / Organisasi : ............................................................................................ 49. Kemasyarakatan / Organisasi : ............................................................................................
50. Lain - Lain : ............................................................................................ 50. Lain - Lain : ............................................................................................
: ............................................................................................ : ............................................................................................
: ............................................................................................ : ............................................................................................
: ............................................................................................ : ............................................................................................
: ............................................................................................ : ............................................................................................
KEGEMARAN PERKEMBANGAN SISWA KEGEMARAN PERKEMBANGAN SISWA
51. Menerima Bea Siswa : Tahun ......................./TK......................dari..................... 51. Menerima Bea Siswa : Tahun ......................./TK......................dari.....................
: Tahun ......................./TK......................dari..................... : Tahun ......................./TK......................dari.....................
: Tahun ......................./TK......................dari..................... : Tahun ......................./TK......................dari.....................
52. Meninggalkan Sekolah : ............................................................................................ 52. Meninggalkan Sekolah : ............................................................................................
a. Tanggal Meninggalkan Sekolah : ............................................................................................ a. Tanggal Meninggalkan Sekolah : ............................................................................................
b. Alasan : ............................................................................................ b. Alasan : ............................................................................................
53. Akhir Pendidikan : ............................................................................................ 53. Akhir Pendidikan : ............................................................................................
a. Tamat Belajar : ............................................................................................ a. Tamat Belajar : ............................................................................................
b. STTB Sekolah : ............................................................................................ b. STTB Sekolah : ............................................................................................
KETERANGAN SETELAH SELESAI PENDIDIKAN KETERANGAN SETELAH SELESAI PENDIDIKAN
54. Melanjutkan di : Tahun ......................./TK......................dari..................... 54. Melanjutkan di : Tahun ......................./TK......................dari.....................
55. Bekerja : Tahun ......................./TK......................dari..................... 55. Bekerja : Tahun ......................./TK......................dari.....................
a. Tanggal Mulai Kerja : Tahun ......................./TK......................dari..................... a. Tanggal Mulai Kerja : Tahun ......................./TK......................dari.....................
b. Nama Perusahaan / Lembaga : ............................................................................................ b. Nama Perusahaan / Lembaga : ............................................................................................
dan lain lain : ............................................................................................ dan lain lain : ............................................................................................
c. Penghasilan : ............................................................................................ c. Penghasilan : ............................................................................................
: ............................................................................................ : ............................................................................................
: ............................................................................................ : ............................................................................................
: ............................................................................................ : ............................................................................................
LAIN - LAIN LAIN - LAIN
Catat Yang Penting : ............................................................................................ Catat Yang Penting : ............................................................................................
..................................................................................................................................................................... .....................................................................................................................................................................
..................................................................................................................................................................... .....................................................................................................................................................................
..................................................................................................................................................................... .....................................................................................................................................................................
..................................................................................................................................................................... .....................................................................................................................................................................
..................................................................................................................................................................... .....................................................................................................................................................................
..................................................................................................................................................................... .....................................................................................................................................................................
..................................................................................................................................................................... .....................................................................................................................................................................
..................................................................................................................................................................... .....................................................................................................................................................................
Nomor Induk Siswa : .................................. No Urut Nomor Induk : ..................................
Kelas : ........................................... Kelas : ...........................................
Semester : ........................................... Semester : ...........................................
1. Nama Siswa THN Pelajaran : ........................................... THN Pelajaran : ...........................................
a. Nama Lengkap : ................................................................ Mata Pelajaran
Pas Photo Pengetahuan Pengetahuan Pengetahuan Pengetahuan
b. Nama Panggilan : ................................................................ Ukuran (Kl 3) (Kl 3) (Kl 3) (Kl 3)
2. Jenis Kelamin : Laki Laki / Perempuan ....................... 3x4
(1/6) Nilai Huruf Nilai Huruf Nilai Huruf Nilai Huruf
3. Tempat dan Tanggal Lahir : ................................................................
4. Agama : ................................................................ Kelompok A (Wajib)
5. Kewarganegaraan : WNI / WNI Keturunan
Pendidikan Agama Islam
6. Anak Ke : ........................dari................................. dan Budi Pekerti
7. Jumlah Saudara : ................................................................ Cap tiga Jari Tangan Kiri
Mengenai Pas Foto Bagian a. Al-Qur’an Hadis
a. Kandung : ................................................................ Bawah Waktu Masuk
b. Tiri : ................................................................ b. Aqidah Akhlaq
Tanda Tangan
c. Angkat : ................................................................ c. Fikih
8. Anak Yatim/ Yatim Piatu : ................................................................
9. Kegiatan Sehari Hari Di rumah : ................................................................ (..................................) d. Sejarah Kebudayaan Islam
Pendidikan Pancasila dan
Kewarganegaraan
10. Alamat : ............................................................... Bahasa Indonesia
: ...............................................................
Bahasa Arab
11. Nomor Telepon : ...............................................................
12. Tinggal Dengan Orang Tua/Saudara : ............................................................... Matematika
Asrama / Kost : ............................................................... Ilmu Pengetahuan Alam
13. Jarak Tempat Tinggal Ke Sekolah : ...............................................................
Ilmu Pengetahuan Sosial
Pas Photo
Ukuran Bahasa Inggris
3x4 Kelompok B (Wajib)
14. Golongan Darah : ............................................................... (1/6)
15. Penyakit Yang Pernah Di derita : ............................................................... Seni Budaya
TBC/Cacar/Malaria Dll : ............................................................... Pendidikan Jasmani,
16. Kesehatan Jasmani : ............................................................... Olah Raga dan Kesehatan
17. Tinggi Dan Berat Badan : ............................................................... Prakarya dan Kewirausahaan
Cap tiga Jari Tangan Kiri
Mengenai Pas Foto Bagian
KETERANGAN PENDIDIKAN Bawah Waktu Masuk
Kelompok C ( Muatan Lokal )
18. Pendidikan Sebelumnya a. Bahasa Daerah
Tanda Tangan
a. Lulusan Dari : ...............................................................
b. ...............................................
b. Tangga dan Nomor STTB : ...............................................................
(..................................) c. ...............................................
c. Lama Belajar : ...............................................................
19. Pindahan d. ...............................................
a. Dari Sekolah / Madrasa : ...............................................................
e. ...............................................
b. Alasan : ...............................................................
20. Diterima DI sekolah Ini Kegiatan Ekstra Kurikuler Keterangan Keterangan
a. Di tingkat : ............................................................... a. Pramuka
b. Kelompok : ...............................................................
...............................................
c. Jurusan : ...............................................................
d. Tanggal : ............................................................... ...............................................
Pas Photo
Ukuran ...............................................
KETERANGAN AYAH KANDUNG 3x4 Ketidak Hadiran ........................................................ Hari ........................................................ Hari
21. Nama : ............................................................... (1/6)
22. Tempat dan Tanggal Lahir : ............................................................... Sakit ........................................................ Hari ........................................................ Hari
23. Agama : ............................................................... Izin ........................................................ Hari ........................................................ Hari
24. Kewarganegaraan : ............................................................... Tanpa Keterangan ........................................................ Hari ........................................................ Hari
25. Pendidikan : ............................................................... Cap tiga Jari Tangan Kiri
26. Pekerjaan : ............................................................... Mengenai Pas Foto Bagian Keputusan : Berdasarkan Nilai Yang Di peroleh Pada Semester 1 dan 2 maka Wali Kelas
Bawah Waktu Masuk siswa ini ditetapkan
27. Penghasilan Per Bulan : ...............................................................
28. Alamat Rumah / Nomor Telepon : ............................................................... Naik Ke Kelas ..................................(................................................)
Tanda Tangan
Tinggal Di Kelas ..................................(................................................)
: ............................................................... Tanggal (.........................................)
..................................(................................................)
29. Masih Hidup / Meninggal Dunia Tahun : ............................................................... (..................................)
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