| PANITIA PENERIMAAN SISWA BARU TAHUN PELAJARAN 2012 - 2013 |
| MADRASAH IBTIDAIYAH |
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| Alamat : Desa Kebonagung Kec. Sukodono-Sidoarjo Kode pos 61258 Tlp. 031-8832357 |
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| No. Pendaftaran | | | | | | | |
| I. DATA PRIBADI CALON SISWA |
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| 1 | Nama lengkap |
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| ( sesuai dengan akte kelahiran ) |
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| Nama Panggilan |
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| 2 | Jenis kelamin |
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| | Laki-laki | | Perempuan |
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| 3 | Tempat & tanggal lahir | : |
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| | | - | | | - | | | | | (tanggal, bulan, tahun) |
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| 4 | Usia |
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| | | Tahun |
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| 5 | Alamat |
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| Status Tempat tinggal | : |
| | Ikut Orangtua |
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| | Ikut Saudara / Kerabat |
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| 6 | Telepon |
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| 7 | Kewarganegaraan |
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| | WNI | | WNA …………………………… |
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| 8 | Agama |
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| 9 | Anak ke |
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| 10 | Jumlah saudara kandung | : |
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| 11 | Berat badan/Tinggi badan | : |
| | | Kg |
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| 12 | Golongan Darah |
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| 13 | Bahasa Sehari-hari |
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| 14 | Ukuran baju |
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| | M |
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| | XL |
| | XXL |
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| II. DATA ORANG TUA |
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| 1 | Nama Ayah / Wali |
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| a. Pendidikan terakhir | : |
| | SD |
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| | SMP |
| | SMA |
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| | Diploma | | S1 |
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| b. Pekerjaan |
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| | PNS |
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| | TNI/ POLRI |
| | Karyawan |
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| | Wirausaha |
| | Profesional |
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| c. Alamat |
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| d. Telepon |
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| 2 | Nama Ibu / Wali |
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| a. Pendidikan terakhir | : |
| | SD |
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| | SMP |
| | SMA |
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| | Diploma | | S1 |
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| b. Pekerjaan |
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| | PNS |
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| | TNI/ POLRI |
| | Karyawati |
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| | Wirausaha |
| | Profesional |
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| c. Alamat |
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| d. Telepon |
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| 3 | Penghasilan Orangtua | : |
| | < Rp.500.000,- |
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| | Rp. 2.000.001,- s/d Rp. 3.000.000,- |
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| Per bulan |
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| | Rp. 500.001 s/d Rp. 1.000.000,- | | Rp. 3.000.001,- s/d Rp. 5.000.000,- |
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| | Rp. 1.000.001,- s/d Rp. 2.000.000,- | | > Rp. 5.000.000,- |
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| III. KETERANGAN PENDIDIKAN SEBELUMNYA |
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| a. Asal Sekolah |
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| b. Alamat Sekolah Asal | : |
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| UNTUK SISWA MUTASI |
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| a. Asal Mutasi Sekolah | : |
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| b. Alamat Sekolah Asal | : |
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| c. NISN |
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| Sidoarjo, ……………………………… |
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| Pendaftar / Orang tua |
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| ( ………………………………………… ) |
| KETERANGAN : |
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| 1. Penulisan isian formulir menggunakan huruf balok |
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| 2. No. Pendaftaran akan diisi oleh Panitia Penerimaan Siswa Baru (PSB) |
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| 3. Beri tanda X (silang) pada isian pilihan |
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| 4. Pengembalian Berkas PSB disertai dengan: |
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| a. Formulir Pendaftaran Siswa Baru yang sudah diisi dan ditanda tangani orangtua siswa |
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| b. Pas Foto berwarna 3x4 ( 4 lembar ) |
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| c. Fotocopy Akta Kelahiran (1 lembar) |
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| d. Fotokopi Ijazah terakhir (TK) 1 lembar |
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| e. Membayar uang Pendaftaran sebesar Rp. 30.000,- |
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| 5. Pendaftar dinyatakan diterima jika setelah 1 minggu melaksanakan registrasi minimal 50% |
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| dari biaya daftar ulang |
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| 6. Jika setelah melaksanakan registrasi dan mengundurkan diri maka biaya registrasi |
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| dianggap sebagai INFAQ |
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| 7. Pelunasan Registrasi paling akhir tanggal 27 - 28 Juni 2012 |
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| 8. Pelaksanaan Pre test tanggal 25 Juni 2012 |
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| 9. Pengumuman hasil Pre test dan pembagian kelas tanggal 27 Juni 2012 |
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| 10. Pengambilan seragam dilaksanakan pada tanggal 27-28 Juni 2012 |
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| 11. Pelaksanaan test IQ dilakukan 1 minggu setelah tahun pelajaran baru dimulai |
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