YAYASAN PONDOK PESANTREN TERPADU AL-HIKAM

Akta Notaris No.: 02/ Not/ I/ tgl 6 Juni 2003. NPWP No : 02.399.584.8-526.000
SK. Menteri Hukum dan HAM RI No.: C-126. HT.01.02. tgl 31 Januari 2005
Alamat : Dk. Sorowaden, Jl. Solo-Boyolali Km 17, Kec. Banyudono, Kab. Boyolali 57373
Telp : 0276-3294400 / 085640432187 / 085647036964
FORM. C-1
IDENTIFIKASI CALON ANAK ASUH

A. IDENTITAS CALON ANAK ASUH

1. Nama lengkap : .......................................................................................................
2. Nama panggilan : ..........................................................................  L / P*
3. Tempat, tanggal lahir : .......................................................................................................
4. Kewarganegaraan : .......................................................................................................
5. Agama : .......................................................................................................
6. Urutan kelahiran : Anak ke ……… dari …….. bersaudara kandung
7. Pendidikan terakhir : .......................................................................................................
8. Kegemaran / hobby : .......................................................................................................
9. Alamat : .......................................................................................................
Nomor, RT, RW : .......................................................................................................
Desa / Kelurahan : .......................................................................................................
Kecamatan : .......................................................................................................
Kabupaten / Kota : .......................................................................................................
Provinsi : .......................................................................................................

B. IDENTITAS ORANGTUA AYAH KANDUNG IBU KANDUNG

1. Nama : ................................................... ...............................................
2. Tempat, tanggal lahir : ................................................... ...............................................
3. Kewarganegaraan : ................................................... ...............................................
4. Agama : ................................................... ...............................................
5. Pendidikan terakhir : ................................................... ...............................................
6. Kondisi :  Masih ada /  Meninggal  Masih ada /  Meninggal
7. Pekerjaan : ................................................... ...............................................
8. Penghasilan per bulan : ................................................... ...............................................
9. Pernikahan ke : …… pada usia ……… tahun …… pada usia ……… tahun
10. Status pernikahan :  Masih /  Bercerai  Masih /  Bercerai
Alamat : ................................................... ...............................................
Nomor, RT, RW : ................................................... ...............................................
Desa / Kelurahan : ................................................... ...............................................
Kecamatan : ................................................... ...............................................
Kabupaten / Kota : ................................................... ...............................................
Provinsi : ................................................... ...............................................
11. Kartu identitas / KTP : ................................................... ...............................................
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C. SUSUNAN KELUARGA
Susunan saudara sekandung / tiri dari anak asuh (nama anak asuh dicantumkan)
No. Nama L/P Umur Pendidikan/Pekerjaan Keterangan
1
2
3
4
5

D. IDENTITAS WALI / KELUARGA PENGGANTI *

1. Nama lengkap :......................................................................................................
2. Tempat, tanggal lahir :......................................................................................................
3. Kewarganegaraan :......................................................................................................
4. Agama :.....................................................................  L / P*
5. Hubungan :......................................................................................................
6. Pendidikan terakhir :......................................................................................................
7. Pekerjaan :......................................................................................................
8. Penghasilan per bulan :......................................................................................................
9. Jumlah tanggungan :......................................................................................................
10. Alamat :......................................................................................................
Nomor, RT, RW :......................................................................................................
Desa / Kelurahan :......................................................................................................
Kecamatan :......................................................................................................
Kabupaten / Kota :......................................................................................................
Provinsi :......................................................................................................
11. Nomor telepon :......................................................................................................
12. NIK :......................................................................................................

E. ASAL CALON ANAK ASUH

No Asal Calon Anak Asuh Keterangan
1  Rujukan Dari : …
2  Permohonan keluarga
3  Penjangkauan lembaga
4  Lain-lain, sebutkan

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F. CATATAN RIWAYAT SOSIAL

1. LATAR BELAKANG CALON ANAK ASUH
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2. PERKEMBANGAN CALON ANAK ASUH
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3. RIWAYAT KESEHATAN CALON ANAK ASUH
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4. RIWAYAT PENDIDIKAN CALON ANAK ASUH

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5. KONDISI LINGKUNGAN
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6. MASALAH CALON ANAK ASUH
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7. HAL LAIN-LAIN
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G. KRITERIA MASALAH SOSIAL KELUARGA CALON ANAK ASUH

1.  kemiskinan;
alasan : ......................................................................................................................
2.  ketelantaran;
alasan : ......................................................................................................................
3.  kecacatan;
alasan : ......................................................................................................................
4.  keterpencilan;
alasan : ......................................................................................................................
5.  ketunaan sosial dan penyimpangan perilaku;
Alasan : ......................................................................................................................
6.  korban bencana;
alasan : ......................................................................................................................
7.  korban tindak kekerasan, eksploitasi dan diskriminasi
alasan : ......................................................................................................................

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H. DOKUMEN PENDUKUNG
1. Akta kelahiran anak asuh ................................................ : [ ] Ada / [ ] Tidak ada
2. Pasfoto anak asuh ............................................................ : [ ] Ada / [ ] Tidak ada
3. Buku rapor / ijazah anak asuh ......................................... : [ ] Ada / [ ] Tidak ada
4. Kartu Keluarga anak asuh ............................................... : [ ] Ada / [ ] Tidak ada
5. KTP ayah anak asuh ........................................................ : [ ] Ada / [ ] Tidak ada
6. KTP ibu anak asuh .......................................................... : [ ] Ada / [ ] Tidak ada
7. KTP wali anak asuh ......................................................... : [ ] Ada / [ ] Tidak ada
8. ..................................................................................................................................................
9. ..................................................................................................................................................
10. ..................................................................................................................................................

I. KESIMPULAN dan SARAN

1. Kesimpulan Petugas Sosial
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2. Saran Petugas Sosial
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Tempat dan tanggal dibuat

Mengetahui, Petugas Sosial,

Kepala LKSA AL-Hikam,

…………………… ……………………

J. HASIL SIDANG PEMBAHASAN PENERIMAAN ANAK ASUH

No. Pelaksanaan Sidang Keterangan
1 Hari dan tanggal pelaksanaan
2 Peserta sidang 1)
2)
3)
4)
5)
3 Hasil sidang
 Diterima menjadi anak asuh Sejak tanggal
Jangka waktu pengasuhan tahun
Nomor Induk Anak (NIA)
 Ditolak menjadi anak asuh Alasan :

 Keputusan lain : Alasan :