FORMULIR PENDAFTARAN PESERTA DIDIK

SMK YAPAN
TAHUN PELAJARAN 2024/2025
TANGGAL PENDAFTARAN : - - 2 0 2 4
NO. REGISTRASI PENDAFTARAN : 2 4 - 2 5 -
JENIS PENDAFTARAN : PESERTA DIDIK BARU

PESERTA DIDIK PINDAHAN

PROGRAM KEAHLIAH : TEKNIK KOMPUTER DAN JARINGAN

AGRIBISNIS TANAMAN PANGAN DAN HORTIKULTURA

A. IDENTITAS CALON PESERTA DIDIK BARU

1. Nama lengkap : ..........................................................................................................................................................
2. Tempat, tanggal lahir : ..........................................................................................................................................................
3. NISN :
4. NIK :
5. Jenis Kelamin : ..........................................................................................................................................................
6. Anak Ke : ..........................................................................................................................................................
7. Status dalam keluarga: : ..........................................................................................................................................................
8. Agama :
9. Kewarganegaraan : ..........................................................................................................................................................
10. Telp/HP : ..........................................................................................................................................................
11. Alamat :
: ..........................................................................................................................................................
B. IDENTITAS ORANG TUA/ WALI
1. Nama Ayah/ Wali : ..........................................................................................................................................................
2. Pekerjaan : ..........................................................................................................................................................
3. Pendidikan Terakhir : ..........................................................................................................................................................
4. Nama Ibu : ..........................................................................................................................................................
5. Pekerjaan : ..........................................................................................................................................................
6. Pendidikan Terakhir : ..........................................................................................................................................................
7. Telp/HP : ..........................................................................................................................................................
8. Alamat :
: ..........................................................................................................................................................
C. ASAL SEKOLAH
1. Nama sekolah : ..........................................................................................................................................................
2. Tahun Lulus : ..........................................................................................................................................................
3. Alamat sekolah : ..........................................................................................................................................................
4. Nomor Seri Ijazah : ..........................................................................................................................................................
D. PRESTASI YANG PERNAH DIRAIH
1. Bidang :
Juara : .........................................................................................................................................................
Tingkat : .........................................................................................................................................................
Tahun : .........................................................................................................................................................
RIWAYAT KESEHATAN CALON PESERTA DIDIK
2. Golongan Darah : ..........................................................................................................................................................
3. Berat Badan : ..........................................................................................................................................................
4. Tinggi Badan : ..........................................................................................................................................................
5. Riwayat Penyakit : ..........................................................................................................................................................

E. PEMINATAN EKSTRAKURIKULER
 PASKIBRA  PENCAK SILAT  MARAWIS  VOLLY BALL
 PRAMUKA  PADUAN SUARA  ROHIS  FUTSAL
 ROBOTIKA SENI TARI  TEATER 
BADMINTON 
Saya menyatakan dengan sesungguhnya bahwa isian data dalam formulir ini adalah benar. Apabila ternyata data tersebut tidak
benar / palsu, maka saya bersedia menerima sanksi berupa Pembatalan sebagai Calon Peserta Didik SMK YAPAN
Parakansalak – Sukabumi

Sukabumi, ……………...…….......... 2024

Mengetahui
Petugas Verifikasi Orang Tua/Wali Calon Peserta Didik Baru

(…………………..……….….) (…………………..……….….) (…………………..……….….)

Tanda Tangan dan Nama Jelas Tanda Tangan dan Nama Jelas Tanda Tangan dan Nama Jelas
FORMULIR PENDAFTARAN PESERTA DIDIK
SMK YAPAN
TAHUN PELAJARAN 2024/2025