MADRASAH DINIYAH TAKMILIYAH MIFTAHUSSA’ADAH

Kp. Jamilega Desa. Kertamukti Kec. Ciawi Kab.

Tasikmalaya Kode Pos. 46156 Telp.
085719076534
FORMULIR PENDAFTARAN SISWA BARU

I. SISWA
1. Nama
a. Nama Lengkap : ......................................................................................
b. Nama Panggilan : ......................................................................................
2. Tempat, Tgl Lahir : ......................................................................................
3. NIK : ......................................................................................
4. Jenis Kelamin : ......................................................................................
5. Agama : ......................................................................................
6. Kewarganegaraan : ......................................................................................
7. Anak Ke : ......................................................................................
8. Jumlah Saudara : ......................................................................................
9. Status Anak dalam Keluarga : Anak Kandung/ Anak Angkat/ Lainnya : ................
10. Alamat Siswa
a. Alamat : ......................................................................................
b. Telepon/HP : ......................................................................................
11. Di Terima di Madrasah
a. Di Kelas : ......................................................................................
b. Pada Tanggal : ......................................................................................
12. Nama RA/ TKA Asal
a. Nama Sekolah : ......................................................................................
b. Alamat Sekolah : ......................................................................................
13. Nama SD/ MI Asal
a. Nama Sekolah : ......................................................................................
b. Asal Sekolah : ......................................................................................
14. Aktivitas yang Disukai : a. ..................................................................................
b. ..................................................................................
15. Cita-cita : ......................................................................................
II. ORANG TUA
1. Nama Lengkap Ayah : ......................................................................................
NIK : ......................................................................................
2. Nama Lengkap Ibu : ......................................................................................
NIK : ......................................................................................
3. Alamat Ayah/ Ibu : ......................................................................................
Kecamatan : ......................................................................................
Kelurahan : ......................................................................................
4. Telepon/ HP : ......................................................................................
5. Pekerjaan Ayah : ......................................................................................
6. Pekerjaan Ibu : ......................................................................................
7. Pendidikan Terakhir Orangtua :
a. Ayah : ......................................................................................
b. Ibu : ......................................................................................
8. Penghasilan Orangtua : Rp..................................................................................

Ketentuan:
1. Formulir ini harus diisi dengan lengkap oleh siswa
2. Setelah pengisian, formulir diserahkan ke Guru masing-masing
3. Melampirkan Foto Copy Kartu Keluarga dan Akta Kelahiran

Tasikmalaya, .................................................

Calon Siswa Baru Kepala Sekolah

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