FORM PPDB

Penerimaan Siswa Baru 202_-202_

HILLMAYA KIDS

Pas poto

3x4

Nama Siswa

…………………………………………………………………………………..

BERKAS PENDAFTARAN

Foto Copy KK 2 Lembar Foto Copy KTP Orang tua

Foto Copy Akte lahir 2 lembar Buku KIA

 FORM PPDB
Penerimaan Siswa Baru 202__-2024__

HILLMAYA KIDS

REGISTER SISWA

1. No Pendaftaran : .........................................................................................................
2. Jenis Pendaftaran : Siswa Baru / Siswa Pindahan ( MUTASI ) / Mengulag
( Coret yang tidak perlu )

3. Tanggal Masuk Sekolah/ Mendaftar : .........................................................................................................

4. Sekolah Asal Mutasi : .........................................................................................................
( isi dengan nama sekolah asal mutasi jika siswa Mutas/jika bukan kosongkani)

5. NISN Siswa : .........................................................................................................

( Isi NISN, Apabila Sudah punya jika belum dterbitkan oleh PUSDATIN)

IDENTITAS SISWA

6. Nama Lengkap : .........................................................................................................

7. Jenis Kelamin : .........................................................................................................
8. Kewarganegaraan : .........................................................................................................
9. NIK : .........................................................................................................
10. No KK : .........................................................................................................
11. Tempat/Tgl Lahir : .........................................................................................................
12. No Reg Akte Lahir : .........................................................................................................
13. Agama : .........................................................................................................
14. Alamat Lengkap :
Nama jalan : .........................................................................................................
RT/RW : ....................................................../..................................................
Nama Dusun/KP/Komp : .........................................................................................................
Desa/Kelurahan : .........................................................................................................
Kecamatan : .........................................................................................................
Kabupaten/Kota : .........................................................................................................
Provinsi : .........................................................................................................
Kode Pos : .........................................................................................................
15. Tinggal Bersama : .........................................................................................................
16. Moda Transportasi : .........................................................................................................
17. Anak Ke : .........................................................................................................
 KESEJAHTERAAN

18. Penerima Kartu KIP/KKS/KPS/PKH : .........................................................................................................

19. Nomor Kartu KIP/KKS/KPS/PKH : .........................................................................................................
20. Nama Pada Kartu KIP/KKS/KPS/PKH : .........................................................................................................
21. Anak Yatim/ Piyatu : .........................................................................................................
22. Siswa Miskin : .........................................................................................................

PERIODIK SISWA
DIK
23. Tinggi Badan : .........................................................................................................
24. Berat Badan : .........................................................................................................
25. Lingkar kepala : .........................................................................................................
26. Penyakit yang pernah diderita : .........................................................................................................
27. Hoby dan Cita-Cita : .........................................................................................................
28. Jarak Tempuh ( m/km) : .........................................................................................................
29. Jumlah saudara : .........................................................................................................
30. Waktu tempuh : .........................................................................................................

ORANG TUA

( Isi data ayah dan ibu meski sdh meninggal, jika sudah meninggal isi pekerjaan Sudah Meninggal, Penghasilannya Rp. 0 )
31. Nama Ayah : .........................................................................................................
NIK Ayah : .........................................................................................................
Tempat/Tgl Lahir Ayah : .........................................................................................................
Pendidikan Ayah : .........................................................................................................
Pekerjaan Ayah : .........................................................................................................
Penghasilan Ayah : .........................................................................................................
No HP Ayah : .........................................................................................................

32. Nama Ibu : .........................................................................................................

NIK Ibu : .........................................................................................................
Tempat/Tgl Lahir Ibu : .........................................................................................................
Pendidikan Ibu : .........................................................................................................
Pekerjaan Ibu : .........................................................................................................
Penghasilan Ibu : .........................................................................................................
No HP Ibu : .........................................................................................................
 DATA WALI SISWA

( Isi data ayah dan ibu meski sdh meninggal, jika sudah meninggal isi pekerjaan Sudah Meninggal, Penghasilannya Rp. 0 )

33. Nama Wali Siswa : .........................................................................................................

Jenis kelamin : .........................................................................................................
NIK Ayah : .........................................................................................................
Tempat/Tgl Lahir Ayah : .........................................................................................................
Pendidikan Ayah : .........................................................................................................
Pekerjaan Ayah : .........................................................................................................
Penghasilan Ayah : .........................................................................................................
No HP Ayah : .........................................................................................................

PERNYATAAN

1. Semua data yang telah kami isi adalah benar dan tervalidasi dapat dipergunakan dan
dipertanggungjawabkan untuk data Dapodik Dan Lainnya
2. Apabila dikemudian hari ada kesalahan data yang diisikan pada lembar ini maka segala akibat
dari kesalahan ini kami tanggung dan tidak akan menyalahkan siapapun
3. Kami berikan hak penggunaan data ini kepada Operator Pendataan Dapodik / Sekolah guna
keperluan sebagaimana mestinya

Panitia PPDB ………………………………………………..

Orang Tua/Wali

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