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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
1
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
2
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
6
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
7