REGISTRATION FORM

ACADEMIC YEAR : 2017-2018

3x4

Number of Registration Form :……………………………..

Main Number of Student :…………………………….. (will filled in by the officer)

Date of Registration Form Received :……………………………..

Date of Registration Form Returned :……………………………..

Registered for Grade : 1 2 3 4 5 6

1. DATA OF STUDENT

Full Name (in capital) ………………………………………………………………………………………………………………………………………………………………………….

……………

Name to be used at school …………………………………………………………………..… Sex L P

I’m the ……………….. child Type of Blood A B AB O

Place & Date of Birth ………………………………………………………………………….. Date…………….. Month…………………………. Year………………………………

Nationality ………………………..……………………………………...………............ Religion ………….……………………………………………………………………….....

Student Resides with Mother Father Both Parents Guardian Grandparent Uncle Others ………………………………………..

Address ………………………………………………………………………………………………… Height of Body …………………………………………………….……………………

…………………………………………………………………………………………………………….. Weight of body …………………………………………………………………………..

…………………………………………………………………………………………………………….. Language at Home ………………………………………………………………………

2. DATA OF PARENTS

Full Name (Father)………………………………………….......................................... (Mother) …………………………………………………………………………………….

Place & Date of Birth…………………………………………………………….…………..….. …………………..…………………………………………………………………..………….

Nationality ……………………………………….…………………………………….………..…. …………………………………………………………………………….…………………….

Address…………………………………………………………………………….……..……........ ………………………………………………………………………..………………………….

Home Phone.…………………………………………HP…………….…………………..……… ……………………………………………………………………..…………………………….

E-Mail ………………………………………………………………………………………………… ………………………………………………………………..………………………………….

Religion…………………………….……………………………………….………………..………. …………………………………………………………..……………………………………….

Last Academic Level ……………………………………………………………………………. ………………………………………………………..………………………………………….

Name & Address of Office …………………………………………………..………………. ………………………………………………………..………………………………………….

………………………………………………………………………..…………………………………. …………………………………………………….…………………………………………….

……………………………………………………………………..……………………………………. ……………………………………………………..…………………………………………….

3. Names of Siblings / Age / School 4. Emergency Contact :

…………………………………….…….………………………………….…………..………… …… Name………………………………….……………………………………………………

……………………………….……………………….……………………………..………………..… Relationship with child ………………….…..……………………………………...

……………………………………………………………………………………………………………. Home Phone…………………………….…HP…………..……………………………

We (undersigned), state that we have thoroughly read the above form and filled in the requirements data truly. There for we understand and accept
all the consequences related to the data.

Jakarta,…………..…………………..
………………………………… …………………………………
Signature of the Father/Relative Signature of the Mother/Relative

ADMISSION REQUIREMENTS

___________________________________

1. Returned Registration Form

2. Child’s recent photograph (size : 3 x 4 / color) / 4 photos / Back color Blue /
White Muslim Cloth
3. Child’s recent photograph (size : 4 x 6 / color) / 2 photos
4. Child’s recent photograph (size : 3 x 4 / black & white) / 4 photos
5. Photocopy of father’s KTP / 1 piece
6. Photocopy of mother’s KTP / 1 piece
7. Photocopy of family registration card / 1 piece
8. Photocopy of KG certificate / 1 piece

Previous School

_____________________

Name of Previous School : ________________________________

Address : __________________________________________________
__________________________________________________
____________________________________________

We got the information about AISC from :

_____________________________________________________

Website Neighbor

Banner Teacher of AISC

Brochure Parents of AISC

Newspaper ……………………………………………..

Friend
 GUARDIAN IDENTIFICATION FORM
(for identifying those people responsible for dropping off and picking up the child)

Number of Registration Form :……………………………..

Name of Child :

Name to be used at school :

1. First Person

Full Name (as on KTP) :

Name used :

No KTP : ________________________

Address (as on KTP) :

Relationship with child : Grandparent

Uncle
Recent
Baby sitter Colored
Photograph
Maid
3x4
Private Driver

School Driver

…………………………………………..

2. Second Person (if any)

Full Name (as on KTP) :

Name used :

No KTP : ________________________

Address (as on KTP) :

Relationship with child : Grandparent

Uncle
Recent
Baby sitter Colored
Photograph
Maid
3x4
Private Driver

School Driver

………………………………………………

Jakarta,……………………………..

Signature of Father / Mother

.

MEDICAL RECORD
(Should be filled in by the parent)

Full Name ______________________________________________________________

Date & Place of Birth _______________________________________Height _______________ Weight __________________

Sex L P Type of Blood A B AB O

Address ____________________________________________________________________________________

Home Phone ____________________________________________________________________________________

Father’s Hand Phone ____________________________________________________________________________________

Mother’s Hand Phone ____________________________________________________________________________________

1. Past History
Type Yes / No Date Type Yes / No Date

Skin Problem Urinary Disorder

Asthma Tuberculosis

Diabetes Epilepsy

Heart Disorder Fainting Spells

Meningitis Scoliosis

2. Does your child have any present illness ?

If Yes, describe : ___________________________________________________________________________

__________________________________________________________________________

3. Any record about allergy ?

If Yes, describe : ____

______________________________________________________________________________________

4. Hospitalization serious injuries :

Why ? ________________________________________________________________________

When ? ________________________________________________________________________

5. Does your child able to participate in sports :

If No, describe : _________________________________________________________________________

________________________________________________________________________

We parent of _____________________________ give the valid data for the school and allow them to give any possible treatment in
emergency.

Jakarta,______________________
 Signature of Father Signature of Mother
*please attach the medical record from the hospital (if any)

GENERAL PERMIT STATEMENT

FOR OUTDOOR ACTIVITIES
__________________________________________________________________

We parents of _________________________

1. Permit him/her to participate in all school activities.

2. Will not follow the activities and travel and trust to the school 100 %.

3. Will not hold the school responsible for any damage which may occur during activities and travel

Jakarta, _______________________________

Signatures

_______________ ________________
Signature of Father Signature of Mother

___________________
School Representative
 PARENTS STATEMENT
REGARDING OF TAHFIZH DEVELOPMENT

Statement of intent
Date : ___________________________
We the undersigned, parents of
Name : ___________________________

Do hereby state that we have known and understood that Tahfizh Al-Quran is the most prioritized program
except language (Arabic & English) skill development and IT in Azhari Islamic School Cilandak.

There for, to realize our goal, We agree to spare our time seriously to help our child in Tahfizh Al-Quran at
home and agree to be proactive in communicating with the teachers of Tahfizh.

And we agree that if AISC requests us to come to school regarding the conduct of our child, we will
respond positively and come to the school in order to discuss any matters concerning our child. We
understand that if for whatever reason we do not come to school after three invitations, AISC has the right
to expel our child from school.

Signatures

__________________ ____________________
Signature of Father Signature of Mother

__________________________
School Representative