FORMULIR PENDAFTARAN ANAK DIDIK BARU

FORMULIR PENDAFTARAN ANAK DIDIK BARU

SD NEGERI 1 KUBANG

Tahun Pelajaran  : 2014 / 2015

A.    KETERANGAN ANAK DIDIK

1.         Nama Lengkap                                         :  ..............................................................................

2.         Jenis Kelamin                                           :  ..............................................................................

3.         Tempat Tanggal Lahir                              :  ..............................................................................

4.         Agama                                                      :  ..............................................................................

5.         Kewarganegaraan                                                :  ..............................................................................

6.         Anak Nomor ke                                       :  ..............................................................................

7.         Jumlah Saudara Kandung                        :  ..............................................................................

8.         Jumlah Saudara Tiri                                 :  ..............................................................................

9.         Tinggi Badan/ Berat Badan                     :  ..…............…………Cm /……...........………Kg

10.     Penyakit Berat yang pernah diderita       :  ..............................................................................

11.     Alamat Rumah                                         :  ..............................................................................

12.     Jarak dari Rumah ke Sekolah                   :  ..............................................................................

B.     ORANG TUA / WALI

1.      Nama  :      -     Ayah Kandung                 :  ..............................................................................

-          Ibu Kandung                     :  ..............................................................................

2.      Tempat Tanggal Lahir  :

-          Ayah                                 :  ..............................................................................

-          Ibu                                     :  ..............................................................................

3.      Pendidikan  :

-          Ayah                                 :  ..............................................................................

-          Ibu                                     :  ..............................................................................

4.      Pekerjaan   :

-          Ayah                                 :  ..............................................................................

-          Ibu                                     :  ..............................................................................

C.    ASAL MULA ANAK

1.      Masuk SD ini sebagai                               :  Anak Didik Baru / Pindahan

a.       Nama TK                                            :  ..............................................................................

b.      Alamat                                                :  ..............................................................................

2.      Jika murid pindahan, pindahan dari          :

a.       Nama SD                                            :  ..............................................................................

b.      Alamat                                                :  ..............................................................................

c.       Nomor Induk Siswa Nasional(NISN)            :  ..............................................................................

d.      Masuk di SD ini dikelas                      :  ..............................................................................

3.      Diterima di SD ini  :

a.       Tanggal                                               :  ..............................................................................

D.    DITERIMA/ DITOLAK

Alasan  :   ........................................................................................................................................

                 ........................................................................................................................................

Pas foto 3x4

                                                                                   

                                                                        Kubang, ........, ...................., 2014
                                                                                   WALI WURID

                                                                                             ( ............................................ )            

CATATAN

Harus dilampirkan

1. Photo Copy Akte Kelahiran

2. Photo Copy Kartu Keluarga

3. Photo Copy Kartu Perlindungan Sosial (jika punya).