IDENTITAS PESERTA DIDIK

1. Nama Lengkap : ...........................................................................................

2. Nomor Induk/NISN : ...........................................................................................
3. Tempat Tanggal Lahir : ...........................................................................................
4. Jenis Kelamin : ...........................................................................................
5. Agama : ...........................................................................................
6. Anak Ke : ...........................................................................................
7. Pendidikan Sebelumnya : ...........................................................................................
8. Alamat Siswa : ...........................................................................................
Telepon / HP : ...........................................................................................
9. Diterima di Sekolah ini : ...........................................................................................
a. Di Kelas : ...........................................................................................
b. Pada Tanggal : ...........................................................................................
10. Sekolah Asal : ...........................................................................................
a. Di Kelas : ...........................................................................................
b. Alamat : ...........................................................................................
11. Nama Orang Tua : ...........................................................................................
a. Ayah : ...........................................................................................
b. Ibu : ...........................................................................................
12. Alamat Orang Tua : ...........................................................................................
Telepon / HP : ...........................................................................................
13. Pekerjaan Orang Tua : ...........................................................................................
a. Ayah : ...........................................................................................
b. Ibu : ...........................................................................................
14. Nama Wali : ...........................................................................................
15. Alamat Wali : ...........................................................................................
Telepon / Hp : ...........................................................................................
16. Pekerjaan Wali : ...........................................................................................

............................... ...........................20........
Kepala Sekolah,
Pas Foto
Ukuran
3 x 4 Cm

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NIP:
Nama Peserta Didik : .......................................... Kelas : ................................
Nomor Induk / NISN : .......................................... Semester : ................................
Nama Sekolah : .......................................... Tahun Pelajaran : ................................
Alamat Sekolah : ...................................................................................................................
...................................................................................................................

A. Sikap

Aspek Catatan ( Deskripsi )

Menerima dan Menjalankan
ajaran agama yang dianutnya

Menunjukkan perilaku jujur,

disiplin,tanggung jawab,santun,
peduli,percaya diri,dalam,
berinteraksi dengan keluarga dan
guru

B. Pengetahuan

Aspek Catatan ( Deskripsi )

Mengingat dan memahami
pengetahuan faktual dan
konseptual berdasarkan rasa ingin
tahu tentang :
 dirinya,
 makhluk ciptaan Tuhan dan
kegiatannya
 benda-benda lain di sekitarnya
c. Keterampilan

Aspek Catatan ( Deskripsi )

Menyajikan kemampuan mengamati,
menanya,dan mencoba dalam :

- bahasa yang jelas,logis dan

sistematis
- karya yang estetis

- gerakan anak sehat

- tindakan anak beriman dan

berakhlak mulia

D. Ekstra Kurikuler

No Kegiatan Keterangan
1. Praja Muda Karana 
( PRAMUKA )

2. Diisi jenis ekstra kurikuler  .............................................................................

Pilihan yang diikuti siswa
.................................................... .............................................................................
.............................................................................

3.

E. Saran-Saran
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Ketidakhadiran
Sakit : ........... hari
Izin : ........... hari
Tanpa Keterangan : ........... hari

Mengetahui ........................................................20..................
Orang Tua / Wali Guru Kelas,

.............................................. ......................................................................
NIP:
A. Perkembangan Fisik / Kesehatan

N Semester
Apek Yang Dinilai
O 1 2
1. Tinggi ............. cm ............. cm
2. Berat Badan ............. kg ............. kg

B. Kondisi Kesehatan

No Aspek Fisik Keterangan

1. Pendengaran

2. Penglihatan

3. Gigi

4. Lainnya ............................

C. Catatan Prestasi

No Jenis Prestasi Keterangan

1.

2.

3.

Mengetahui ........................................................20..................
Orang Tua / Wali Guru Kelas,

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NIP: