No. Induk Santri : _____________________

A. KETERANGAN SANTRI

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

2. Nama Panggilan : .....................................................................................

3. Tempat/Tgl Lahir : .....................................................................................

4. Jenis Kelamin : L/P

5. Jumlah Saudara : ....................anak ke ...................................................

6. Alamat : .....................................................................................

B. KETERANGAN ORANG TUA

1. Nama Orang Tua

a. Ayah : .....................................................................................

b. Ibu : .....................................................................................

2. Pendidikan

a. Ayah : .....................................................................................

b. Ibu : .....................................................................................

3. Pekerjaan

a. Ayah : .....................................................................................

b. Ibu : .....................................................................................

4. Alamat Orang Tua : .....................................................................................

No. Telpon : ................................... Hp............................................

C. KETERANGAN WALI

1. Nama Wali : .....................................................................................

2. Alamat Wali : .....................................................................................

No. Telpon : ................................... Hp............................................

3. Hub. Dengan Anak : a. Kakek b. Nenek c. Paman

d. Lainnya. Sebutkan ..................................................

D. PERKEMBANGAN SANTRI

1. Khotam Al-Qur’an/Tidak Khotam:

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

b. Syahadah No. : .....................................................................................

2. Melanjutkan ke

a. Madin : .....................................................................................

b. Ponpes : .....................................................................................

c. Lainnya : .....................................................................................