PEMERINTAH KABUPATEN ACEH UTARA NO :

DINAS PENDIDIKAN DAN KEBUDAYAAN

SD NEGERI 7 SYAMTALIRA ARON
Jln. Banda Aceh - Medan Desa Dayah Teungku Kode Pos 24381
Email : sdn7syamtaliraaron@gmail.com

FORMULIR SISWA BARU SDN 7 SYAMTALIRA ARON

TAHUN PELAJARAN 2023/2024

I. DATA PRIBADI
1. Nama Lengkap : .........................................................................
2. Nama Panggilan : .........................................................................
3. NIK : .........................................................................
4. No KK : .........................................................................
5. NISN : .........................................................................
6. Jenis Kelamin : .........................................................................
7. Tempat Lahir : .........................................................................
8. Tanggal Lahir : .........................................................................
9. Agama : .........................................................................
10. Kewarganegaraan : .........................................................................
11. Kebutuhan Khusus : .........................................................................
12. Alamat
- Jalan : .........................................................................
- Dusun : .........................................................................
- Desa : .........................................................................
- Kecamatan : .........................................................................
- Kode Pos : .........................................................................
13. Tinggal Bersama : .........................................................................
14. Transportasi Kesekolah : .........................................................................
15. Data Rinci
- Tinggi Badan : .........................................................................
- Berat Badan : .........................................................................
- Jarak Rumah Kesekolah : .........................................................................
- Waktu Tempuh Kesekolah : .........................................................................
- Anaka Ke : .........................................................................
- Jumlah Saudara Kandung : .........................................................................
16. Status Yatim/Piatu : .........................................................................
II. AYAH KANDUNG
1. Nama Ayah Kandung : .........................................................................
2. NIK Ayah : .........................................................................
3. Tahun Lahir : .........................................................................
4. Pendidikan : .........................................................................
5. Pekerjaan : .........................................................................
6. Penghasilan Perbulan : .........................................................................
III. IBU KANDUNG
1. Nama Ibu Kandung : .........................................................................
2. NIK Ibu : .........................................................................
3. Tahun Lahir : .........................................................................
4. Pendidikan : .........................................................................
5. Pekerjaan : .........................................................................
6. Penghasilan Perbulan : .........................................................................

IV. WALI
1. Nama Wali Kandung : .........................................................................
2. NIK Wali : .........................................................................
3. Tahun Lahir : .........................................................................
4. Pendidikan : .........................................................................
5. Pekerjaan : .........................................................................
6. Penghasilan Perbulan : .........................................................................

V. KONTAK
1. Nomor HP Orang Tua/Wali : .........................................................................

VI. SEKOLAH ASAL

1. Nama Sekolah : .........................................................................
2. NPSN : .........................................................................
3. Alamat : .........................................................................

Panitia Dayah Teungku, ………………….

Penerimaan Siswa Baru Orang Tua /Wali

Asmaul Husna, S.Pd …………………………

Mengetahui :
Kepala Sekolah

Mahdi, S.Pd
Nip. 19760120 200701 1 004
Lampiran :
1. Fotocopy Ijazah TK
2. Fotocopy Kartu NISN
3. Fotocopy KK
4. Fotocopy KTP Orang Tua
5. Pas Photo 3x4 = 4 Lbr dan 2x3 = 4 Lbr
(Foto layar merah, pakai seragam SD, dan bukan foto scan)
6. Surat keterangan kurang mampu (bagi siswa kurang mampu)