YAYASAN KHOIRUL USROH

MADRASAH TSANAWIYYAH (MTs) KHOIRUL USROH

Jl. TalunKidul Gg. Majlis N0. 20 Talun Sumedang UtaraTlp. (0261) 2138697
Email : khoirulusroh@yahoo.com

FORMULIR PENERIMAAN PESERTA DIDIK

MADRASAH TSANAWIYYAH (MTs) KHOIRUL USROH
KECAMATAN SUMEDANG UTARA KABUPATEN SUMEDANG
TAHUN PELAJARAN 2023 / 2024
Nama Lengkap : ...........................................................................................
Tempat, Tanggal Lahir : ...........................................................................................
Jenis Kelamin : ...........................................................................................
Agama : ...........................................................................................
Status Dalam Keluarga : Anak Kandung Anak Tiri Anak Angkat

Anak Ke : ...........................................................................................
Alamat : ...........................................................................................
Telepon / HP : ...........................................................................................
Asal Sekolah : ...........................................................................................
Penyakit yang pernah diderita/masih : .............................................................................
Nama Orangtua : ...........................................................................................
1. Ayah :..........................................................................................
Pekerjaan : ...........................................................................................
Pendidikan terakhir : ...........................................................................................
2. Ibu :..........................................................................................
Pekerjaan : ...........................................................................................
Pendidikan terakhir : ...........................................................................................
Penghasilan Orangtua : Rp ........................................................................................
Alamat Orangtua : ...........................................................................................
Persyaratan :
No Persyaratan Keterangan
1 Photo 3x4 hitam putih 4 lembar berseragam sekolah (khusus calon siswa
perempuan wajib berkerudung)
2 Photo copy STTB Dan SKHUN atau keterangan duduk di kelas VI SD/ MI
3 Photo copy Akta Kelahiran
4 Photo copy NISN (kartu biru)
5 Photo copy Kartu KJS/ PKH, KIP Dsb.
6 Photo copy Ijazah TPA

Diisi Oleh MTS Khoirul Usroh:

Diterima Di Madrasah Ini : ...........................................................................................
Sumedang, ...................................... 2023
Mengetahui,
Orangtua Calon Siswa Baru

( .................................................... ) ( .................................................... )