FORMULIR PENDAFTARAN SANTRI BARU

MUHAMMADIYAH BOARDING SCHOOL (MBS) PROF. HAMKA KOTA MADIUN

TAHUN PELAJARAN 2024/2025

*) Dilingkari Pendaftaran Reguler Program Khusus

BAGIAN 1 : Data diri calon santri (diisi dengan huruf cetak sesuai Akte/KK)
No Pendaftaran :
Nama Lengkap : …………………………………………………………………………………………………………………………
Tempat Tanggal Lahir : ..............................................
Jenis Kelamin *) : L / P
Golongan Darah : ........... Kewarganegaraan : ................................................................
NIK :
NISN :
Alamat Lengkap : Dusun/ Jl. ............................................................................................................... RT .........RW …….....
Desa ........................................................……. Kec. .....................................................................
Kab./ Kota .................................................... Prov. …………………………………………….....
Jumlah Saudara Kandung: .......... (………………………………….)
Golongan Darah : ………………………………………………………
No. Telepon Rumah : ............................................................................
Asal Sekolah : ...........................................................................................................................................................................
Alamat Sekolah : ...........................................................................................................................................................................
Telepon Sekolah : ....................................................................................
Prestasi : ................................................................. Tingkat :..............................................................
BAGIAN 2 : DATA KELUARGA
Nama Ayah Kandung : ............................................................................................................................................................................
Pendidikan : ............................................................ Pekerjaan : ............................................................
Nama Ibu Kandung : ............................................................................................................................................................................
Pendidikan : ............................................................ Pekerjaan : ............................................................
Alamat : Dusun/ Jl. ......................................................................................... RT ....... RW .........
Desa ................................................................. Kec. .....................................................................
Kab./ Kota ........................................................ Prov. ………………………………………………..
Nomor HP Ayah : ...................................................
Nomor HP Ibu : ...................................................
Gaji Ayah *) : 1. < 1.000.000 2. 1.000.000 – 2.000.000 3. > 2.000.000
Gaji Ibu *) : 1. < 1.000.000 2. 1.000.000 – 2.000.000 3. > 2.000.000
Nama Wali : ..............................................
No. HP : ..............................................
Alamat : ..............................................
BAGIAN 3 : KEBUTUHAN KHUSUS DAN RIWAYAT PENYAKIT
Kebutuhan Khusus : .......................................................................
Penyakit : ....................................................................... Lamanya : .................... tahun.
Catatan Orang Tua : ............................................................................................................................................................................

Mengetahui,
Orang Tua/Wali

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