| KETERANGAN PESERTA DIDIK |
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| Nama Lengkap | : | .................................................. |
| Nama Panggilan | : | .................................................. |
| Jenis Kelamin | : | .................................................. |
| Tempat/Tgl. Lahir | : | .................................................. |
| Anak Keberapa | : | .................................................. |
| Jumlah Saudara Kandung | : | .................................................. |
| Jumlah Saudara Tiri | : | .................................................. |
| Jumlah Saudara Angkat | : | .................................................. |
| Anak Yatim/Piatu/Yatim Piatu | : | .................................................. |
| Bahasa Sehari-Hari | : | .................................................. |
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| KETERANGAN TEMPAT TINGGAL |
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| Alamat Lengkap | : | .................................................. |
| Nomor Telepon Rumah | : | .................................................. |
| Tinggal Pada Orang Tua/Menumpang/D iasrama | : | .................................................. |
| Jarak Tempat Tinggal ke Sekolah | : | .................................................. |
| Ke Sekolah dengan | : | .................................................. |
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| KETERANGAN JASMANI |
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| Berat Badan | : | .................................................. |
| Tinggi Badan | : | .................................................. |
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| KETERANGAN PENDIDIKAN |
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| Asal Sekolah | : | ................................................. |
| Tanggal/Thn dan No. Ijazah | : | ................................................. |
| Nilai/Indek Prestasi (IP) | : | ................................................. |
| Lamanya Belajar | : | ................................................. |
| (Jika Siswa Pindahan) | : | ................................................. |
| Pindah dari Sekolah | : | ................................................. |
| Alasan Pindah | : | ................................................. |
| Diterima di Sekolah ini | : | ................................................. |
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| KETERANGAN ORANG TUA/WALI |
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| Orang Tua | : | ................................................ |
| Nama Ayah | : | ................................................ |
| Nama Ibu | : | ................................................ |
| Alamat/Tempat Tinggal | : | ................................................ |
| Nomor Telepon | : | ................................................ |
| Tempat, Tanggal Lahir Ayah | : | ................................................ |
| Tempat, Tanggal Lahir Ibu | : | ................................................ |
| Pekerjaan Ayah | : | ................................................ |
| Pekerjaan Ibu | : | ................................................ |
| Pendidikan Tertinggi Ayah | : | ................................................ |
| Pendidikan Tertinggi Ibu | : | ................................................ |
| Rekening Sekolah Atas Nama | : | ................................................ |
| Wali |
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| Nama Wali | : | ................................................ |
| Jenis Kelamin | : | ................................................ |
| Tempat, Tanggal Lahir | : | ................................................ |
| Alamat dan Tempat Tinggal Wali | : | ................................................ |
| Pekerjaan Wali | : | ................................................ |
| Pendidikan Tertinggi Wali | : | ................................................ |
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Pendaftar
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Cimarga, ............... 2013
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