KB-1 KB-2 TK-A TK-B SD SMP SMA

FORMULIR PENDAFTARAN SISWA BARUTAHUN PELAJARAN

No. (diisi petugas)

Assalamu’alaikum Warahmatullahi Wabarakatuh

Yang bertanda tangan dibawah ini,

Nama : .............................................................................................................................................

Umur : .............................................................................................................................................

Pekerjaan : (sebutkan secara jelas) .......................................................................................................

Alamat tempat bekerja/kantor (lengkap)

: .................................................................................................................................

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

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

Mengajukan permohonan kepada Kepala untuk menerima

anak kandung/ asuh/ angkat Kami:

Nama lengkap : .................................................................................................................................

Nama panggilan : .................................................................................................................................

Tempat & tgl. Lahir : .................................................................................................................................

Untuk menjadi siswa kelas : ..................... ( ..................... )

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

Wassalamu’alaikum Warahmatullahi Wabarakatuh

Orang tua/ wali siswa

________________________ Nama jelas

PAUD Terpadu (KB1 - KB2, TK-A, TK-B, SD-kelas awal)SMP, SMA (full day - boarding)Jalan Raya Parpostel, Jati Asih, Bekasi - Jawa Barat

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DATA SISWA DAN ORANG TUA/ WALI SISWA

A. Keterangan siswa (diisi selegkapnya dengan huruf balok)

1. Nama siswa : a. lengkap : .........................................................................................................

b. panggilan : .........................................................................................................

2. Jenis kelamin : laki-laki/ perempuan * )

3. Kelahiran : tanggal : .........................................................................................................

tempat : .........................................................................................................

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

5. Kewarganegaraan : WNI/ WNA keturunan * )

6. Jumlah saudara : a. kandung : .............. orang

b. tiri : .............. orang

c. angkat : .............. orang

7. Bahasa sehari-hari di lingkungan keluarga : ............................................................................................

8. Keadaan jasmani

a. berat badan : .............. kg

b. tinggi badan : .............. cm

c. golongan darah : ..........................................................

d. penyakit yang pernah di derita : ..........................................................

9. Alamat lengkap : .................................................................................................................................

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

................................................................................... tlp.........................................

10. Bertempat tinggal pada : orang tua/ menumpang/ asrama * )

11. Jarak tinggal ke sekolah : .............. km

12. Pergi ke sekolah : .............. km

13. Kondisi belajar di rumah

a. Memiliki kamar tidur sendiri : ya/ tidak * )

b. Memiliki meja belajar : ya/ tidak * )

c. Pendamping belajar di rumah : ..............................................................................................

* ) coret yang tidak perlu

PAUD Terpadu (KB1 - KB2, TK-A, TK-B, SD-kelas awal)SMP, SMA (full day - boarding)Jalan Raya Parpostel, Jati Asih, Bekasi - Jawa Barat

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A. Keterangan Orang Tua/ Wali Siswa

1. Nama Orang Tua Kandung

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

Ibu : .....................................................................................................................

b. Pendidikan tertinggi

Ayah : .....................................................................................................................

Ibu : .....................................................................................................................

c. Pekerjaan

Ayah : (lengkap/ jelas) ........................................................................................................

Ibu : (lengkap/ jelas) ........................................................................................................

d. Penghasilan/ Bulan

Ayah : (lengkap/ jelas) ............................................................................................

Ibu : (lengkap/ jelas) ............................................................................................

e. Alamat rumah : .....................................................................................................................

....................................................................... tlp.........................................

f. Alamat tempat kerja/ kantor

Ayah : .....................................................................................................................

....................................................................... tlp.........................................

Ibu : .....................................................................................................................

....................................................................... tlp.........................................

2. Wali Siswa (Jika Mempunyai)

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

b. Hubungan dengan keluarga : ..............................................................................................

c. Pendidikan terakhir : ..............................................................................................

d. Pekerjaan (lengkap/ jelas) : ..............................................................................................

e. Penghasilan /bulan : ..............................................................................................

f. Alamat rumah : ..............................................................................................

................................................ tlp.........................................

g. Alamat tempat kerja/ kantor : ..............................................................................................

................................................ tlp.........................................

PAUD Terpadu (KB1 - KB2, TK-A, TK-B, SD-kelas awal)SMP, SMA (full day - boarding)Jalan Raya Parpostel, Jati Asih, Bekasi - Jawa Barat

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C. Data Perkembangan Siswa

1. Pendidikan sebelumnya

a. Nama TK/ SD : .....................................................................................................................

b. Alamat TK/ SD : .....................................................................................................................

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

c. Diterima tanggal : .....................................................................................................................

d. Di tingkat/ kelas : .....................................................................................................................

e. Prestasi yang pernah diraih

Di sekolah : .....................................................................................................................

Di luar sekolah : .....................................................................................................................

Pernah mendapat beasiswa : pernah/ tidak

Kalau pernah dari : .....................................................................................................................

Sebesar : Rp ........................................../bulan

2. Keadaan Jasmani/ Fisik

a. Warna kulit : .........................................................................................................

b. Bentuk wajah : .........................................................................................................

c. Jenis rambut : .........................................................................................................

d. Warna bola mata : .........................................................................................................

e. Kelainan jasmani/ fisik : .........................................................................................................

f. Penyakit yang pernah diderita : .........................................................................................................

g. Penyakit yang sedang diderita : .........................................................................................................

h. Kelainan fisik lain : .........................................................................................................

Diisi dengan sebenarnya di .................................................................. pada tanggal .................................

Nama jelas Tanda tangan

________________________ ________________________

PAUD Terpadu (KB1 - KB2, TK-A, TK-B, SD-kelas awal)SMP, SMA (full day - boarding)Jalan Raya Parpostel, Jati Asih, Bekasi - Jawa Barat

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D. Riwayat Kesehatan

1. Riwayat Kelahiran

a. Lahir di : b. Oleh :

Rumah sakit Dokter

Rumah bersalin Bidan

Rumah Dukun

Lain-lain, sebutkan ..........................................................................

c. Kondisi saat lahir :

Biasa

Sukar, dengan cara ..........................................................................................................................

d. Berat lahir :

Cukup bulan, BB .............................. gr, panjang .............................. cm

Kurang bulan, BB .............................. gr, panjang .............................. cm

Lebih bulan, BB .............................. gr, panjang .............................. cm

2. Keluarga

a. Ibu

Umur : .........................................................................................................

Pekerjaan : .........................................................................................................

Pendidikan : .........................................................................................................

Perkawinan ke : .........................................................................................................

Penyakit yang sering diderita : .........................................................................................................

b. Ayah

Umur : .........................................................................................................

Pekerjaan : .........................................................................................................

Pendidikan : .........................................................................................................

Perkawinan ke : .........................................................................................................

Penyakit yang sering diderita : .........................................................................................................

c. Saudara-saudara

Jumlah anak : .........................................................................................................

Lahir hidup : .........................................................................................................

Lahir meninggal : ...................................., karena .......................................................

Abortus/ keguguran : .........................................................................................................

Meninggal : ...................................., karena .......................................................

Penyakit yang dialami keluarga :

Anak ke Penyakit

................. : .........................................................

................. : .........................................................

PAUD Terpadu (KB1 - KB2, TK-A, TK-B, SD-kelas awal)SMP, SMA (full day - boarding)Jalan Raya Parpostel, Jati Asih, Bekasi - Jawa Barat

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d. Kondisi kesehatan calon siswa

a. Makanan

ASI : sejak usia ........................................ bln s/d ......................................... bln

Susu : sejak usia ........................................ bln s/d ......................................... bln

Kuantitas makanan : cukup/ kurang

Kualitas makanan : cukup/ kurang

Kesulitan makan : ya/ tidak

b. Kekebalan yang diperoleh

Dasar Ulangan

I II III

BCG ................... ................... ................... ......................................................

DPT ................... ................... ................... ......................................................

DT ................... ................... ................... ......................................................

Polio ................... ................... ................... ......................................................

Campak ................... ................... ................... ......................................................

Hepatitis B ................... ................... ................... ......................................................

MMR ................... ................... ................... ......................................................

Lain-lain (sebutkan) ................... ................... ................... ......................................................

c. Alergi terhadap obat-obatan

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

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

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

d. Alergi terhadap makanan-minuman

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

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

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

e. Penyakit alergi yang diderita

Asthma : Ya/ Tidak

Eksema : Ya/ Tidak

Bersin : Ya/ Tidak

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

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

f. Pernah mendapat A.T.S (Anti Tetanus Serum), pada tanggal

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

PAUD Terpadu (KB1 - KB2, TK-A, TK-B, SD-kelas awal)SMP, SMA (full day - boarding)Jalan Raya Parpostel, Jati Asih, Bekasi - Jawa Barat

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g. Penyakit yang diderita

............................................................................... umur .................................

............................................................................... umur .................................

............................................................................... umur .................................

h. Jenis-jenis operasi yang pernah dialami

............................................................................... tanggal .............................

............................................................................... tanggal .............................

i. Perawatan di rumah sakit karena penyakit

............................................................................... tanggal ............................. s/d .................................

............................................................................... tanggal ............................. s/d .................................

............................................................................... tanggal ............................. s/d .................................

Diisi dengan sebenarnya di .............................. pada tanggal .............................

Orang Tua/ Wali Calon Siswa

__________________________

PAUD Terpadu (KB1 - KB2, TK-A, TK-B, SD-kelas awal)SMP, SMA (full day - boarding)Jalan Raya Parpostel, Jati Asih, Bekasi - Jawa Barat

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