LEMBAR BUKU INDUK PESERTA DIDIK

Isilah pernyataan ini dengan

jelas dan dengan huruf BALOK

Nomor Induk Siswa : ................................................................................... NIK : ..........................................................

NISN : ................................................................................... No. KK : ..........................................................

A. KETERANGAN SISWA

1. Nama Siswa
a. Lengkap : ..................................................................................................................
b. Panggilan : ..................................................................................................................
2. Jenis Kelamin : Laki-laki / Perempuan *)
3. Kelahiran : ..................................................................................................................
a. Tanggal : ..................................................................................................................
b. Tempat : ..................................................................................................................
4. Agama : ..................................................................................................................
5. Kewarganegaraan : ..................................................................................................................
6. Jumlah Saudara : ..................................................................................................................
7. Bahasa sehari-hari dirumah : ..................................................................................................................
8. Golongan Darah : ..................................................................................................................
9. Alamat dan nomor telpon : ..................................................................................................................
: ..................................................................................................................
: ..................................................................................................................
10. Bertempat tinggal pada : ..................................................................................................................
11. Jarak sekolah : ..................................................................................................................

B. KETERANGAN ORANG TUA / WALI SISWA

12. Nama Orang tua Kandung

a. Ayah : ..................................................................................................................
b. Ibu : ..................................................................................................................
13. Pendidikan tertinggi
a. Ayah : ..................................................................................................................
b. Ibu : ..................................................................................................................
14. Pekerjaan
a. Ayah : ..................................................................................................................
b. Ibu : ..................................................................................................................
15. Wali Murid
a. Nama : ..................................................................................................................
b. Hubungan Keluarga : ..................................................................................................................
c. Pendidikan terakhir : ..................................................................................................................
d. Pekerjaan : ..................................................................................................................

C. PERKEMBANGAN SISWA

16. Pendidikan sebelumnya

a. Masuk menjadi siswa
1. Asal Sekolah : ..................................................................................................................
2. Nama Sekolah : ..................................................................................................................
3. Tanggal dan Nomor STTB : ..................................................................................................................
b. Pindah dari sekolah lain
1. Asal Sekolah : ..................................................................................................................
2. Dari tingkat : ..................................................................................................................
3. Diterima tanggal : ..................................................................................................................
D. MENINGGALKAN SEKOLAH / MADRASAH
19. Tamat Belajar/Lulus
a. Tahun
b. Nomor Ijazah/STTB
c. Melanjutkan ke sekolah
20. Pindah sekolah
a. Tingkat/Kelas yang ditinggalkan
b. ke Sekolah
c. ke Tingkat
21. Keluar sekolah
a. Alasan Keluar sekolah
b. Hari dan tanggal Keluar sekolah
Mengetahui/Menyetujui
Orangtua / Wali *)
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Nama Jelas
*) coret yang tidak perlu
: ..................................................................................................................
: ..................................................................................................................
: ..................................................................................................................
: ..................................................................................................................
: ..................................................................................................................
: ..................................................................................................................
: ..................................................................................................................
: ..................................................................................................................
Pati, 2023
Yang membuat pernyataan
__________________________________
Nama Jelas