ADNI BANGI SCHOOL (PRESCHOOL/PRIMARY)

Lot 19511,Jalan Teratai, Kg Dato Abu Bakar Baginda, 43650 Bangi, Selangor.
Tel : 010 2889010
E-mail : adnibangi@gmail.com
No. Pendaftaran Pelajar
Registration Number : _______________________________________
Gambar Ukuran
Pasport

Nama Penuh (seperti dalam Sijil Kelahian/ Kad Pengenalan / Passport) :

Full name (as stated in Birth Certificate / I.C. / Passport:
_________________________________________________________
No. Resit
Receipt Number : ___________________________________________

Untuk kegunaan pejabat / for office use only

Tarikh Masuk : Lokasi Kelas
Admission Date: __________________

Class Allocation: _______________

1.

Sila lengkapkan semua maklumat dengan menggunakan HURUF BESAR.

Please complete the form using CAPITAL LETTERS.

2.

Sertakan bersama borang ini:

Please submit with this form the following:
2 keping gambar berukuran paspot
2 passport sized photograph (Malaysian student)
6 passport sized photograph (Foreign Student)
Salinan Sijil Kelahiran dan terjemahan (jika bukan dalam B. Melayu atau B. Inggeris)
Copy of Birth Certificate and translation (if not in Malay or English Language)
Salinan Kad Pengenalan atau Paspot murid
Copy of Identity Card or Passport of the student
Salinan Kad Pengenalan atau Paspot ibu dan bapa
Copy of Identity Card or Passport of the parents
Salinan Sijil Perkahwinan
Copy of Marriage Certificate (Foreign Parents only; for visa purposes)
Salinan Sijil Berhenti Sekolah terdahulu
Copy of Previous School Leaving Certificate
Dokumen-dokumen lain yang berkenaan
Other relevant documents

Note : please ensure that ALL the above are submitted before sending in the registration form to the school office.
Submission without the complete set of documents will not be processed for registration.

A.

MAKLUMAT PERIBADI MURID

STUDENTS PARTICULARS

1.

Umur
Age

: ______________________

2. No Sijil Kelahiran
Birth Certificate No : _____________________
Mykid No

3.

Tempat Lahir
Place of Birth : ____________________

5.

4. Warganegara
Nationality

:_____________________

: ___________________

Alamat Rumah
Home Address : __________________________________________________________
________________________________________________________________________

6.

Sekolah-sekolah terdahulu
Previous schools attended:

No.

Tahun /
Year

Sekolah / School

Gred /
Grade

1
2
3
7.

Bahasa pertuturan
Spoken language

: i) _________________________________
ii) _________________________________
iii) _________________________________

B.

BUTIRAN ADIK-BERADIK
SIBLINGS INFORMATION

No

Nama Adik-beradik / Siblings name

Tarikh lahir
Date of birth

1
2
3
4
5
Anak ke_____________ daripada ____________ adik-beradik
Child number

of

siblings

Sekolah / School

C.

SEJARAH KESIHATAN
MEDICAL HISTORY

1.

Adakah anak anda mempunyai sebarang alahan

Does your child have any allergies:
Ya/Yes

Tidak/No

Nyatakan/Please state

a) Ubatan / Medicine

______________________

b) Imunisasi / Immunization

______________________

c) Makanan / Food

______________________

d) Lain-lain / Others

______________________

2.

Adakah anak anda mengalami atau pernah mengalami penyakit/masalah berikut

Does your child have/had any of illness/problem:
Ya/Yes

Tidak/No

Nyatakan/Please state

a) Lelah / Asthma

______________________

b) Sawan / Epilepsy

______________________

c) Lain-lain / Others

______________________

D.

MAKLUMAT IBUBAPA
PARENTS INFORMATION

Details
Nama
Name :
No. Kad
Pengenalan /
Passport
I.C. No. / Passport
:
Warganegara
Nationality :
Kelulusan
Tertinggi
Highest
Education :
Pekerjaan
Occupation :
Pendapatan
Income :
Majikan
Employer :
Jenis Perniagaan
Nature of
Business :
Alamat Pejabat
Office Address :

No. Telefon
Rumah
House Tel. No :
No. Telefon
Pejabat
Office Tel. No :

Bapa / Fathers

Ibu / Mothers

No. Telefon Bimbit

Mobile No :
Email
Email :

E.

MAKLUMAT PENJAGA
GUARDIANS INFORMATION

1.

Nama
Name

: _______________________________________________________

2.

No. K. P / Paspot
I.C. No. / Passport : _______________________________________________________

3.

Warganegara
Nationality

: ___________________

Pekerjaan
Occupation

: ________________________________________________________

Majikan
Employer

: ________________________________________________________

Alamat
Address

: ________________________________________________________

5.
6.
7.

4. Hubungan
Relationship : _________________

8.

Nombor telefon
Telephone Number: (H)_________________ (O) _______________ (M) _____________

F.

PERAKUAN
DECLARATION
Segala keterangan dan butir-butir yang di berikan di dalam borang ini adalah tepat dan
benar.
All the information given in this application form is true and correct.
Tarikh :
Date : _________________________
Nama :
Name : _________________________

G.

Tandatangan
Signature

:
: ______________________

PERSETUJUAN
AGREEMENT
Saya faham dan bersetuju terhadap perkara berikut:
1

Notis 2 bulan adalah diperlukan untuk pengembalian wang deposit.

2 months notice must be served before withdrawal or the deposit will be forfeited.
2.

Segala baki tertunggak akan ditolak dari wang deposit ini dan baki yang ada akan
dikembalikan.
Any outstanding payment will be deducted from the deposit.

Nama Murid
Students Name

: ___________________________________________________________

Nama Ibubapa/penjaga
Parents/Guardians Name

: ___________________________________________________

Tandatangan:
Signature: _______________________________

Tarikh:
Date : ______________________

H. CONSENT FOR CLINIC/ HOSPITAL TREATMENT

I, .. parent/guardian of
, Mykid No/Birth Cert. No
Agree that in cases of emergency my child/children be taken for treatment at the clinic chosen by
the school. In the event that my child/children need to be taken to a hospital, please take him/her to
the hospital below. (Please tick the appropriate)
HOSPITAL PUTRAJAYA
HOSPITAL SERDANG
HOSPITAL AN-NUR, BANGI
HOSPITAL AZ-ZAHRAH, BANGI
ANY HOSPITAL CHOSEN BY THE SCHOOL
I agree to bear all the cost charged by the clinic/hospital.
Name

: _____________________________________________

Address

: _____________________________________________
_____________________________________________
_____________________________________________

Phone No: Mobile: ___________________ Home: _______________________

Signature: _______________________

Date: ______________________

----------------------------------------------------------------------------------------------------------------------------------I. TRANSPORTATION
(Adni does not provide any transportation, but we would try to assist, based on the requirements)

Does your child need transportation? If yes, please give address.

Morning only
After school only
Morning and after school

Page7