KETERANGAN TENTANG DIRI PESERTA DIDIK
1. Nama Peserta Didik (Lengkap) : ..................................................................................
2. NIS : ..................................................................................
3. NISN : ..................................................................................
4. Tempat, Tanggal Lahir : ..................................................................................
5. Jenis Kelamin : ..................................................................................
6. Agama : ..................................................................................
7. Status Dalam Keluarga : ..................................................................................
8. Anak Ke : ..................................................................................
9. Alamat Peserta Didik : ..................................................................................
..................................................................................
Telepon / Hp : ..................................................................................
10. Sekolah Asal : ..................................................................................
a. Nomor ljasah : ..................................................................................
b. Tahun : ..................................................................................
11. Diterima di Sekolah ini : ..................................................................................
Di kelas : ..................................................................................
Pada Tanggal : ..................................................................................
12. Nama Orang Tua : ..................................................................................
a. Ayah : ..................................................................................
b. Ibu : ..................................................................................
13. Alamat Orang Tua : ..................................................................................
..................................................................................
Telepon / Hp : ..................................................................................
14. Pekerjaan Orang Tua
a. Ayah : ..................................................................................
b. Ibu : ..................................................................................
15. Nama Wali : ..................................................................................
16. Alamat Wali : ..................................................................................
..................................................................................
Telepon / Hp : ..................................................................................
17. Pekerjaan Wali : ..................................................................................
18. Alamat Email Peserta Didik : ..................................................................................
19. Nama Blog : ..................................................................................
20. Nama FB / Twitter / Lainnya : ..................................................................................
21. Hobi : ..................................................................................
22. Cita – Cita : ..................................................................................
Bogor, .... Maret 2012
Orang Tua / Wali, Peserta Didik,
______________ _________________
Nama Jelas Nama Jelas
Wali Kelas VII H,
Wira Rahayu, S.Pd.,M.M.Pd.
NIP. 196606062007011021
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