Student Registration Form
Student's Particulars
Child's full name (as on birth certificate) *
Preferred name *
Gender *
Place of birth *
Date of birth *
MM
/
DD
/
YYYY
Blood type *
Class entering / Start Date *
Refer to table below (example: N1/July, 2017)
Nationality *
Passport Number
Required for non-Indonesians
Spoken Language at Home *
Religion *
Home address *
Previous school
Current Grade Level *
Write N/A if not applicable
Name and country of last school *
Write N/A if not applicable
NISN *
Only applicable from P2 onwards
Language of Instructions *
Write N/A if not applicable
Student resides with *
Father's Information
Father's name *
Father's birth date *
MM
/
DD
/
YYYY
Father's Nationality *
Father's Religion *
Father's last education *
Father's Mobile number *
Father's Home phone number *
Father's Occupation *
Father's Company *
Father's office phone number *
Write N/A if not applicable
Father's email *
Write N/A if not applicable
Mother's Information
Mother's name *
Mother's birth date *
MM
/
DD
/
YYYY
Mother's nationality *
Mother's Religion *
Mother's last education *
Mother's Mobile number *
Mother's Home phone number *
Mother's occupation *
Write N/A if not applicable
Mother's Company *
Write N/A if not applicable
Mother's office phone number *
Write N/A if not applicable
Mother's Email Address *
Write N/A if not applicable
Emergency Contact
Close relative or friend (other than parents) who can assume responsibility for the child in case of an emergency
Name of Emergency Contact *
Relation *
Emergency Contact Home Phone Number *
Emergency Contact Mobile Phone Number *
Sibling
Name of Sibling
Sibling's Gender
Sibling's Date of Birth
MM
/
DD
/
YYYY
Sibling's School Currently Attending
N/A if not applicable
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