1. DATA CALON PESERTA DIDIK
A. KETERANGAN TENTANG SISWA
1. Nama Lengkap : ______________________________________________________________
2. Nama Panggilan : ______________________________________________________________
3. JenisKelamin (*) : Laki – Laki / Perempuan
4. Tempat/ Tanggal Lahir : ______________________________________________________________
5. NIK(Lihatdi KSK) : ______________________________________________________________
6. Agama : ______________________________________________________________
7. SukuBangsa : ______________________________________________________________
B. KETERANGAN TENTANG KELUARGA
8. AnakKe : ______( ) Dari _______ ( ) Saudara
9. JumlahSaudaraKandung : ______________________________________________________________
10. JumlahSaudaraTiri : ______________________________________________________________
11. JumlahSaudaraAngkat : ______________________________________________________________
12. Status : ______________________________________________________________
13. Bahasa sehari-hari : ______________________________________________________________
C. KETERANGAN TEMPAT TINGGAL
14. TempatTinggal (*) : Tinggal denganorangtua / Saudara/ Kost / Lainya ( )
15. Alamat tempattinggal : ______________________________________________________________
16. NomorTelepon : ______________________________________________________________
17. Jarak TempatTinggal ke Sekolah: _____________________________________________________________
18. AlatTransportasi : ______________________________________________________________
19. Waktu TempuhBerangkatke sekolah : ___________________________(jika lebihdari 60 menit,sebutkan)
D. KETERANGAN TENTANG KESEHATAN
20. GolonganDarah : ______________________________________________________________
21. Penyakityangpernahdiderita : ______________________________________________________________
22. Kelainankesehatanlainya : ______________________________________________________________
23. Tinggi danberat badan : __________ cm,__________Kg.
24. BerkebutuhanKhusus : ______________________________________________________________
E. KETERANGAN TENTANG PENDIDIKAN
25. Lulusdari SLTP / sederajat :______________________________________________________________
26. NISN : ______________________________________________________________
27. NIS : ______________________________________________________________
28. NOMOR SERI IJAZAHSMP : ______________________________________________________________
29. NOMER SERI SKHUN : ______________________________________________________________
30. No UjianNasional SMP/MTs : ______________________________________________________________
31. Tanggal dan nomor STTB : ______________________________________________________________
32. Lama Belajar : ______________________________________________________________
F. KEGEMARAN / HOBBY
33. Kesenian : ______________________________________________________________
34. Olahraga : ______________________________________________________________
35. Kemasyarakatan/Organisasi : ______________________________________________________________
36. Lain – lain : ______________________________________________________________
G. KETERANGAN TENTANG AYAH KANDUNG
37. Nama Lengkap : ______________________________________________________________
38. Alamat : ______________________________________________________________
39. NomorTelepon : ______________________________________________________________
40. Tempat/ Tanggal Lahir : ______________________________________________________________
41. Agama : ______________________________________________________________

2. 42. SukuBangsa : ______________________________________________________________
43. PendidikanTerakhir : ______________________________________________________________
44. Pekerjaan : ______________________________________________________________
45. Penghassilanperbulan : ______________________________________________________________
46. Masih hidup/Meninggal Dunia : ______________________________________________________________
H. KETERANGAN TENTANG IBU KANDUNG
47. Nama Lengkap : ______________________________________________________________
48. Alamat : ______________________________________________________________
49. NomorTelepon : ______________________________________________________________
50. Tempat/ Tanggal Lahir : ______________________________________________________________
51. Agama : ______________________________________________________________
52. SukuBangsa : ______________________________________________________________
53. PendidikanTerakhir : ______________________________________________________________
54. Pekerjaan : ______________________________________________________________
55. Penghasilanperbulan : ______________________________________________________________
56. MassihHidup/Meninggal Dunia: ______________________________________________________________
I. KETERANGAN TENTANG WALI
57. Nama Lengkap : ______________________________________________________________
58. Alamat : ______________________________________________________________
59. NomorTelepon : ______________________________________________________________
60. Tempat/ Tanggal Lahir : ______________________________________________________________
61. Agama : ______________________________________________________________
62. SukuBangsa : ______________________________________________________________
63. PendidikanTerakhir : ______________________________________________________________
64. Pekerjaan : ______________________________________________________________
65. Penghasilanperbulan : ______________________________________________________________
66. MassihHidup/Meninggal Dunia: ______________________________________________________________
Surabaya, 2015
Mengetahui :
Orang Tua / Wali CalonSiswa
...................................................... .......................................................
Tanda Tangan &Nama Terang Tanda Tangan & Nama Terang
Keterangan :
*) Coret Yang Tidak Perlu