DATA PRIBADI PESERTA DIDIK

A. KETERANGAN PRIBADI
1. a. Nama Lengkap : .....................................................................................
b. Nama Panggilan : .....................................................................................
2. Jenis Kelamin : .....................................................................................
3. Tempat, Tanggal lahir : .....................................................................................
4. Agama : .....................................................................................
5. Kewarganegaraan : .....................................................................................
6. Anak ke berapa : .....................................................................................
7. Jumlah saudara kandung : .....................................................................................
(tidak termasuk yang bersangkutan)
8. Jumlah saudara tiri : .....................................................................................
9. Jumlah saudara angkat : .....................................................................................
10. Anak yatim/piatu/ Yatim piatu : .....................................................................................
11. Bahasa sehari-hari di rumah : .....................................................................................

B. KETERANGAN TEMPAT TINGGAL

12. Alamat lengkapsesuai KK : .....................................................................................
.......................................................................................
13. Alamat domisili : .....................................................................................
.......................................................................................
14. Nomor telepon/ HP : .....................................................................................
15. Tinggal pada orang tua/
Menumpang/kost/asrama/pondok : .....................................................................................
16. Jarak dari tempat tinggal : ....................................................................................
17. Alattransportasikesekolah : .....................................................................................

C. KETERANGAN KESEHATAN
18. Golongan darah : .....................................................................................
19. Penyakit yang pernah diderita : .....................................................................................
(TBC, Cacar, Malaria,dll)
20. Kelainan jasmani lainnya : .....................................................................................
21. Tinggi dan berat badan : .....................................................................................

D. KETERANGAN PENDIDIKAN
22. Pendidikan sebelumnya
a. Tamatan dari : .....................................................................................
b. Tanggal dan Nomor ijazah : .....................................................................................
c. Tanggal dan Nomor SKL/SKHUN :......................................................................................
d. Lama belajar : .....................................................................................
23. Pindahan : .....................................................................................
a. Dari sekolah : .....................................................................................
b. Alasan : .....................................................................................
24. Diterima di sekolahini : .....................................................................................
a. Di Kelas :......................................................................................
b. BidangKeahlian :......................................................................................
c. Program Keahlian :......................................................................................
d. Keahlian :......................................................................................
e. Tanggal/Bulan/Tahun :......................................................................................

E. KETERANGAN TENTANG AYAH KANDUNG

25. Nama : .....................................................................................
26. Tempat/Tanggal Lahir : .....................................................................................
27. Agama : .....................................................................................
 28. Kewarganegaraan : .....................................................................................
29. Pendidikan : .....................................................................................
30. Pekerjaan : .....................................................................................
31. Penghasilan per bulan :......................................................................................
32. Pengeluaran per bulan : .....................................................................................
33. Alamat rumah : .....................................................................................
34. Nomor telepon/ HP : .....................................................................................
35. Masih hidup/ meninggal dunia (th.) : .....................................................................................

F. KETERANGAN IBU KANDUNG

36. Nama : .....................................................................................
37. Tempat/Tanggal Lahir : .....................................................................................
38. Agama : .....................................................................................
39. Kewarganegaraan : .....................................................................................
40. Pendidikan : .....................................................................................
41. Pekerjaan : .....................................................................................
42. Penghasilan per bulan :......................................................................................
43. Pengeluaran per bulan : .....................................................................................
44. Alamat rumah : .....................................................................................
45. Nomor telepon/ HP : .....................................................................................
46. Masih hidup/ meninggal dunia (th.) : .....................................................................................

G. KETERANGAN TENTANG WALI

47. Nama : .....................................................................................
48. Tempat/Tanggal Lahir : .....................................................................................
49. Agama : .....................................................................................
50. Kewarganegaraan : .....................................................................................
51. Pendidikan : .....................................................................................
52. Pekerjaan : .....................................................................................
53. Penghasilan per bulan : .....................................................................................
54. Pengeluaran per bulan :......................................................................................
55. Alamat rumah : .....................................................................................
56. Nomor telepon/ HP : .....................................................................................

H. KEGEMARAN PESERTA DIDIK

57. Kesenian : .....................................................................................
58. Olahraga : .....................................................................................
59. Organisasi : .....................................................................................
60. Lain-lain : .....................................................................................

I. PRESTASI YANG PERNAH DIRAIH

NO NAMA LOMBA TINGKAT TAHUN PERINGKAT
1
2
3
4
5

J. HARAPAN PESERTA DIDIK SETELAH LULUS SMK

Kuliah
Bekerja
Berwirausaha/memilikibisnissendiri

*) checklist salah satu

K. CATATAN KESEHATAN YANG MEMBUTUHKAN PERHATIAN KHUSUS

*) KolomProfilPesertaDidikdiisi oleh orang tua/wali

Demikian data pribadi peserta didik ini saya buat dengan sebenarnya dan atas sepengetahuan orang
tua/wali murid.

Mojokerto, ....... Oktober 2023

Mengetahui,

Orang tua/wali murid Siswa yang bersangkutan,

....................................................... .......................................................
(Nama Terang) (Nama Terang)

Catatan Penting:

1. Mengumpulkan Foto Copy IJAZAH tanpa legalisir dan Foto Copy KK masing-masing 1
lembar
2. Foto hitam putih memakai seragam SMP, ukuran 3x4 sebanyak 3 lembar (ditempel)