YAYASAN PENDIDIKAN ISLAM AL-MIFTAH

MADRASAH IBTIDAIYAH SWASTA SETIAMULYA

KABUPATEN TASIKMALAYA
NSM : 111232060038, NPSN : 60708197
Kp. Setiamulya Desa Barumekar Kecamatan Parungponteng Tasikmalaya

FORMULIR PENDAFTARAN PESERTA DIDIK BARU (PPDB)

TAHUN PELAJARAN 2023/2024

A. DATA PESERTA DIDIK

1. Nama Lengkap Peserta Didik : .........................................................................................................
2. NISN (Nomor Induk Siswa Nasional) : .........................................................................................................
3. NIK : .........................................................................................................
4. Tempat, Tanggal Lahir : .........................................................................................................
5. Jenis Kelamin : .........................................................................................................
6. Anak ke- : .........................................................................................................
7. Jumlah Saudara : .........................................................................................................
8. Alamat Peserta Didik : ................................................................ RT/RW ...........................
Desa/Kel : ............................................. Kec. ...................................................
9. Pendidikan sebelumnya :
a. Nama TK/RA/PAUD *) : .........................................................................................................
b. NPSN TK/RA/PAUD *) : .........................................................................................................
c. Alamat TK/RA/PAUD *) : .........................................................................................................
10. Prestasi Siswa : .........................................................................................................

B. DATA ORANG TUA PESERTA DIDIK

1. No. Kartu Keluarga (KK) : .........................................................................................................
2. Nama Lengkap Ayah Kandung : .........................................................................................................
- NIK Ayah : .........................................................................................................
- Pendidikan Ayah : .........................................................................................................
- Pekerjaan Ayah : .........................................................................................................
3. Nama Lengkap Ibu Kandung : .........................................................................................................
- NIK Ibu : .........................................................................................................
- Pendidikan Ibu : .........................................................................................................
- Pekerjaan Ibu : .........................................................................................................
4. No. HP Orang Tua : .........................................................................................................

C. Diterima pada Tanggal : .........................................................................................................

Di kelas : .........................................................................................................

Setiamulya, ........................... 2023

Panitia PPDB, Orang Tua/Wali,

_______________ _________________

Persyaratan dibuat rangkap 2 (dua) dan dimasukkan dalam map: Contact Person:
1. Print Out NISN online terbaru
2. Foto Berwarna ukuran 3x4 (2 buah)
3. Foto Copy Ijazah TK/RA/PAUD
4. Foto Copy Kartu Keluarga (KK)
5. Foto Copy KTP Ayah dan Ibu (digabung menjadi 1 lembar/jangan dipotong)
6. Foto Copy Akta Kelahiran (bagi yang punya)
7. Foto Copy Kartu KIP (bagi yang punya)
8. Foto Copy KKS/ATM PKH/BPNT (bagi orang tua yang mendapat bantuan PKH/BPNT)
Catatan : Semua berkas dicopy di kertas A4 (kertas pendek)