A. KETERANGAN PRIBADI

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2.

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6.

7.

8.

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10.

11.

12.

Nama Peserta Didik

- Nama Lengkap

- Nama Panggilan

Jenis Kelamin

Tempat Lahir

Tanggal Lahir

A g a m a

Kewarganegaraan

Anak ke berapa

Jumlah Saudara Kandung

Jumlah Saudara Tiri

Jumlah Saudara Angkat

Anak yatim/piatu/yatim piatu

Bahasa sehari-hari di rumah

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B. KETERANGAN

13.

14.

15.

Alamat

Nomor Telepon

Tempat Tinggal tersebut adalah

:

:

:

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pada orang tua kandung

pada seseorang dengan hubungan keluarga

menumpang pada orang lain

asrama........................................................................................................

bagi.............................................................................................................

16.

17.

Jarak dari tempat tinggal ke sekolah

Ke sekolah dengan kendaraan

berjalan kaki

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C. KETERANGAN KESEHATAN

Cap tiga jari tengah tangan kiridiatas pas foto bagian bawahwaktu meninggalkan sekolah.

Pas Foto

18.

19.

Berat Badan

Tinggi badan

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Pada waktu terimaPada waktu

Meninggalkan sekolah

20.

21.

Golongan darah

Penyakit yang pernah diderita (contoh TBC, cacar dan lain-lain...............)

: .....................................................

Nomor

UrutJenis Penyakit Kelas Tahun Lama Sakit Keterangan

LEMBAR BUKU INDUK SISWA SMK

Nama Peserta Didik

NIS / NISN

Nama Sekolah

Alamat Sekolah

Kompetensi Keahlian

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.........................................................Cap tiga jari tengah tangan kiridiatas pas foto bagian bawahwaktu meninggalkan sekolah.

Pas Foto

22. Kelamin Jasmaniah / lainnya : ....................................................................................................................................

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D. KETERANGAN PENDIDIKAN SEBELUMNYA23.

24.

Asal Sekolah

a. Tanggal dan Nomor STTB

- Tanggal dan Nomor STTB

- Lama Belajar

b. SLTP lainnya

- Tanggal dan Nomor STTB

- Lama Belajar

a. Pindah dari sekolah

- Diterima disekolah ini

b. Alasan Pindah

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E. KETERANGAN TENTANG ORANG TUA KANDUNG

No. Orang Tua Kandung Ayah Ibu

25.

26.

27.

28.

29.

30.

31.

Nama

Tempat Tanggal Lahir

Kewarganegaraan

Ijazah Terakhir

Pekerjaan

Penghasilan / bulan

Alamat

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F. KETERANGAN TENTANG WALI

No. Wali Laki - Laki Perempuan

32.

33.

34.

35.

36.

Nama

Ijazah Terakhir

Pekerjaan

Penghasilan / bulan

Alamat

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G. KETERANGAN TENTANG WALI

37.

38.

Intelegensi (IQ)

Aspek Kepribadian

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(berdasarkan tes pada tanggal................................bulan............................................

tahun...........................................................................................................................

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No. Aspek yang dinilai Semester Semester Semester Semester Semester Semester Semester Semester Semester

B C K B C K B C K B C K B C K B C K B C K B C K B C K

1.

2.

3.

4.

5.

6.

Disiplin / Ketertiban

Prakarsa / Kreativitas

Tanggung Jawab

Penyesuaian

Kemantapan Emosi

Kerjasama

39. Bakat khusus dan prestasi yang menonjol dalam

No. SMTH / TH Kesenian OlahragaKemasyarakatan

OrganisasiHasta Karya Karya Tulis

1.

2.

3.

1.

4.

5.

6.

7.

8.

H. KETERANGAN KEHADIRAN40. Jumlah hari kehadiran tiap semester :

Semester / Kls HadirTidak Hadir Karena

Sakit Ijin Alpa

Jumlah Hari Belajar

Efektif

Semester......./ Kls......

Semester......./ Kls......

Semester......./ Kls......

Semester......./ Kls......

Semester......./ Kls......

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I. KETERANGAN SEKITAR PERKEMBANGAN PESERTA DIDIK

41.

42.

Tahun Masuk / terdaftar

Prestasi peserta didik

:

:

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Tahun

PelajaranKelas Smt.

Program

Umum

Jumlah

Mat Pel

Nilai

Rata2

Peringkat

Kelas/

Rangking

KhususNilai

Rata2

Nilai

Tinggal

Kelas

20...../20......

20...../20......

20...../20......

43.

44.

45.

Tahun meninggalkan sekolah

dengan alasan

Pindah sekolah ke

Melanjutkan pendidikan ke

:

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J. PENERIMAAN SISWA

Tahun : ................................................................ dari : ..........................................................................................

Tahun : ................................................................ dari : ..........................................................................................

Tahun : ................................................................ dari : ..........................................................................................