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DAFTAR ISIAN BIODATA SISWA SMA NEGERI 23 JAKARTA DATA SISWA 1. Nama Lengkap
: ..................................................................................................
2. Nama Panggilan
: ..................................................................................................
3. Nomor Induk Siswa Nasional (NISN)
: ..................................................................................................
4. Tempat Lahir
: ..................................................................................................
5. Tanggal Lahir
(dd/mm/yyyy)
: ....................../ .............................. /.........................................
6. Jenis Kelamin
: Pria / Wanita *)
7. Agama
: ..................................................................................................
8. Status Diri
: 1. Lengkap
2. Yatim
9. Status Perwalian
: 1. Asuh
2. Wali
10. Anak ke / Dari
: ................................. / ................................ bersaudara
11. Saudara Tiri / Saudara Angkat
: ................................. / ................................
12. Bahasa Ibu
: ..................................................................................................
13. Kewarganegaraan
: 1. WNI
14. Golongan Darah
: ..................................................................................................
3. Piatu.
4. Yatim Piatu *)
*)
2. WNA *)
ALAMAT SISWA 1. Alamat Rumah a. Nama Jalan
: .................................................................................................. : RT...........................RW...........................NO............................
b. Kelurahan
: ..................................................................................................
c. Kecamatan
: ..................................................................................................
d. Kotamadya / Kabupaten
: ..................................................................................................
e. Provinsi
: ..................................................................................................
f. Kode Pos
: ..................................................................................................
2. Telepon
: ..................................................................................................
3. Handphone
: ..................................................................................................
4. Alamat Surat Elektronik (E-Mail)
: ..................................................................................................
5. Tinggal Di
: ..................................................................................................
6. Jarak tempuh ke sekolah
: ...................................Km
7. Transportasi
: ..................................................................................................
DATA KELULUSAN / PENDIDIKAN SISWA 1. Nama SMP/MTs
: ..................................................................................................
2. Alamat SMP/MTs
: ..................................................................................................
3. Tahun Lulus SMP/MTs
: ..................................................................................................
4. No. Ijazah SMP/MTs
: ..................................................................................................
KETERANGAN KESEHATAN
1. Berat Badan
: ............................Kg
2. Tinggi Badan
: ............................Cm
3. Golongan darah
: ............................
4. Penyakit yang pernah diderita (TBC, Cacar, dll)
: .......................................................................................................
5. Tanda Khusus ( ciri – ciri ) Muka Badan Kaki / tangan
: ....................................................................................................... : ....................................................................................................... : .......................................................................................................
KETERANGAN INTELEGENSI DAN KEGEMARAN :
1. Intelegensi ( IQ )
: ...................................................................................................... ( berdasarkan tes tanggal ......................................................... )
2. Aspek Kepribadian NO.
ASPEK YANG DINILAI
1.
Disiplin / Ketertiban
2.
Prakarsa / kreativitas
3.
Tanggung Jawab
4.
Penyesuaian
5.
Kemantapan Emosi
6.
Kerjasama
: ..................................................................................................... BAIK
CUKUP
KURANG
BAKAT KHUSUS DAN PRESTASI YANG MENONJOL :
a. Kesenian
: .................................................................................
b. Olah Raga
: .................................................................................
c. Kemasyarakatan (Organisasi )
: .................................................................................
d. Hasta Karya
: .................................................................................
e. Karya Tulis
: .................................................................................
f. Lain – lain
: .................................................................................
DATA ORANG TUA / WALI DATA AYAH KANDUNG / WALI
DATA IBU KANDUNG / WALI
1. Nama Lengkap
: ................................................
1. Nama Lengkap
: ................................................
2. Prefix (Contoh : Dr. H. Ir)
: ................................................
2. Prefix (Contoh : Dr. H. Ir)
: ................................................
3. Postfix
: ................................................
3.
4. Tempat Lahir
: ................................................
4. Tempat Lahir
: ................................................
5. Tanggal Lahir
: ................./............./..................
5. Tanggal Lahir
: ............../.............../...................
6. Anak
: .......................................orang
6. Anak
: .......................................orang
7. Pendidikan Terakhir
: ................................................
7. Pendidikan Terakhir
: ................................................
8. Kewarganegaraan
: ................................................
8. Kewarganegaraan
: ................................................
9. Bahasa Ibu
: ................................................
9. Bahasa Ibu
: ................................................
10. Agama
: ................................................
10. Agama
: ................................................
11. Pekerjaan
: ................................................
11. Pekerjaan
: ................................................
12. Tingkat/Jabatan Manajerial
: ................................................
12. Tingkat/Jabatan Manajerial
: ................................................
13. Penghasilan
: ....................................../ bulan
13. Penghasilan
: ....................................../ bulan
(Contoh : SH, MA, MBA)
Postfix
(Contoh : SH, MA, MBA)
ALAMAT AYAH KANDUNG / WALI 1.
Alamat Rumah
: ................................................
: ................................................
ALAMAT IBU KANDUNG / WALI 1. Alamat Rumah
: ................................................
: ................................................
: ................................................
: ................................................
: ................................................
2.
Provinsi
: ................................................
2. Provinsi
: ................................................
3.
Kotamadya/Kabupaten
: ................................................
3. Kotamadya/Kabupaten
: ................................................
4.
Kecamatan
: ................................................
4. Kecamatan
: ................................................
5.
Kelurahan
: ................................................
5. Kelurahan
: ................................................
6.
Kode Pos
: ................................................
6. Kode Pos
: ................................................
7.
Telepon
: ................................................
7. Telepon
: ................................................
8.
Handphone
: ................................................
8. Handphone
: ................................................
9.
Alamat Email
: ................................................
9. Alamat Email
: ................................................
Cek bila ya : ......... / .............. / ............
Telah Meninggal Dunia Tanggal Meninggal
Cek bila ya : ......... / .............. / ............
Telah Meninggal Dunia Tanggal Meninggal
Jakarta, ...................................... Mengetahui,
Tanda Tangan Siswa
Orang tua / Wali Siswa
...................................................... Nama Jelas
*) Coret Yang Tidak Perlu / Pilih Salah satu
..................................................... Nama Jelas