YAYASAN BUDDHA TZU CHI WIYATA INDONESIA

TZU CHI SCHOOL

(EARLY CHILDHOOD - PRIMARY - SECONDARY)
Kompleks Tzu Chi Center, Pantai Indah Kapuk Boulevard - Jakarta Utara
Phone : 021 - 5055 6668 Fax : 021 - 5055 6669 www.tzuchi.sch.id

Formulir Aplikasi / Application Form

报名表
ID registrasi : 201809120312

Data Siswa/Student’s Personal Details/学生资料

Mendaftar Tahun Ajaran/Academic Year/

: 2019-2020
就读年份

Kelas/Grade/年级 : Kindergarten 1

Nama Depan/First Name/名 : James

Nama Tengah/Middle Name/中间名字 : Nathan

Nama Keluarga/Last Name/姓 : Winata

Nama Panggilan/Nickname/昵称 : James

Jenis Kelamin/Gender/性别 : Laki-laki

Tempat Kelahiran/Place of Birth/出生地点 : DKI Jakarta

Tanggal Lahir/Date of Birth/出生日期 : 30 Oktober 2015

: Jln. Husein Sastranegara Ruko Duta Garden blok A 1 No.

Alamat/Address/地址
3b Kelurahan Jurumudi, Kecamatan Benda, Tangerang

Telepon/Telephone/电话号码 : 6281289234360

Email/电子邮件 : jamesnathanwinata@yahoo.com
 Agama/Religion/宗教 : Buddha

Kewarganegaraan /Nationality/国籍 : Indonesia

Bahasa Utama /Mother Tongue/母语 : Indonesia

Bahasa Kedua/Second Language/第二语言 :

Bahasa Lain/Other Language/其他语言 :

Rencana Pendidikan berikutnya/Education

: Belum ditentukan / Undecided
Plan/大学未来的计划

Riwayat Pendidikan Siswa/Student’s Education History/教育经历

Tingkatan Sekolah Dari Tahun Sampai Tahun
No. Level School From (Year) Until (Year)
学校 学校 报到日期 离开日期
1 Nursery Apple Tree Preschool 2018 2018

Data Saudara Kandung/Sibling Particulars/兄弟姐妹

Jenis
Nama Tempat/Tanggal Lahir Sekolah & Kelas
Kelamin
No. Name Place/Date of Birth School & Grade
Gender
姓名 出生地点/日期 学校和年级
性别
Universitas
1 Chyntia Winata Perempuan Jakarta / 15-Apr-1996
Tarumanagara / Kuliah
Citra Kasih Junior High
2 Clairine Winata Perempuan Jakarta / 09-Jun-2004
School / 9
Citra Kasih Junior High
3 Jayson Nathan Winata Laki-laki Jakarta / 10-Jul-2005
School / 8
Data Orang Tua/Parents’ Details/家长资料
(Ibu - Mother) (Ayah - Father)

Nama Depan/First Name/名 Venny Tan

Nama Tengah/Middle Name/中间名字 Kartika Hadi

Nama Keluarga/Last Name/姓 Kho Winata

Tempat Lahir/Place of Birth/出生地点 Jakarta Jakarta

Tanggal Lahir/Date of Birth/日期 Sabtu, 24 Maret 1973 Jumat, 10 Desember 1971

Kewarganegaraan/Nationality/国籍 Indonesia Indonesia

Status Pernikahan/Marital Status/婚姻状况 Menikah Menikah

Pekerjaan/Occupation/职业 Wiraswasta - Lainnya Wiraswasta - Lainnya

Pendapatan 50 - 100 Juta
Pendidikan/Education/最高学历/学院 Sarjana
Jln. Husein Sastranegara Ruko
Duta Garden blok A1 no 3B
Alamat Rumah/Home Address/地址
Kelurahan Jurumudi, Kecamatan
Benda, Tangerang
Telepon Rumah/Home Phone No./家庭电话 62215400780
250 - 500 Juta
Sarjana
Jln. Husein Sastranegara Ruko
Duta Garden blok A1 no 3B
Kelurahan Jurumudi, Kecamatan
Benda, Tangerang
62215400780

Telepon Selular/ Cellular Phone No./手机 6281289234360 6281296298897

Telepon Kantor/Work Phone No./工作电话号码

Email/电子邮箱 chyntia.winata@ymail.com

Dalam Kondisi Darurat/In Case of Emergency/在紧急情况下

Nama/Name/名 : Chyntia Winata
Hubungan/Relationship to the Child/关系 : Sister
Telepon Selular/Cellular Phone/手机号码 : 6281212131331
Telepon/Telephone/电话号码 : 62215400849
 Perjanjian/Agreement/同意书
Dalam melakukan pendaftaran ini, saya/kami berkewajiban mematuhi peraturan-peraturan berikut ini:
In making this application, I/we undertake to comply with the following regulations:
通过该应用程序，本人/吾等承诺遵守下列规定：

Mengisi Formulir Aplikasi, Kartu Kesehatan Siswa & Informasi Darurat secara benar.
To fill in the Application Form, Student’s Health Card & Emergency Information correctly.
请明确填写报名表，学生健康卡及紧急联络方式。
Sekolah berhak untuk meminta kami mengakhiri program dengan sekolah untuk alasan-alasan di bawah ini (tetapi tidak terbatas
hanya untuk ini):
The school has the right to ask us to end the program with the school for any of the following reasons (but not solely limited to):
以下情况，学校有权要求学生停学或退学。（非唯一限制条例)：
Gagal dalam mematuhi peraturan-peraturan yang ditetapkan dalam buku panduan orang tua.
Failing to comply with policies set forth in the parent’s handbook.
孩子严重违反学校规则。
Kesehatan dan/atau kondisi emosional anak mempengaruhi murid lainnya.
The child’s health and/or emotional behavior affects other students.
如果学生健康与精神状况严重影响到其他学生，必须停止上课办理退。
Dengan mengisi aplikasi ini, saya/kami bersedia mendukung sekolah untuk mencapai tujuan-tujuannya. Ini termasuk mengenakan
seragam, mengkonsumsi makanan vegetarian di
sekolah dan mendukung perilaku sosial dalam semua hal.
By completing this application, I/we commit myself/ourselves to support the school in the achievement of its aim and objectives. This
includes complying to wear the
uniform, consume vegetarian meals in school and support the social conduct in all respects.
递交本报名表后，我/我们认同并支持与配合学校创校宗旨和目标，也遵守所有校规与学费制度，
包括在校区内须配合穿制服和素食的规定。
Dengan mengisi aplikasi ini, saya setuju dan memberi izin sepenuhnya atas penggunaan informasi anak saya, termasuk – namun
tidak terbatas pada – foto, penghargaan, beasiswa, hadiah, informasi berita sekolah, daftar tim, tugas dan project, kerajinan tangan,
video dan/atau rekaman suara, wawancara, publikasi sekolah dalam seluruh kegiatan pemasaran yang dilakukan oleh Tzu Chi
School. Saya setuju dan memberi izin sepenuhnya atas wawancara yang dilakukan oleh pihak media kepada anak saya serta
pengambilan foto dan/atau video dalam event – event sekolah.
By completing this application, I consent to any publication of my child(ren)’s information which includes – but not limited to –
photographs, awards, scholarships, prizes, newsletter information, team lists, assignments or projects, art work, video and/or audio
recording, interviews, school publications, advertisements, and promotional materials used by Tzu Chi School. I consent to the
interview(s) that my child(ren) has/have to do and to the media coverage of my child(ren) in the event.
完成此申请后，我将同意学校可以公布发表我的孩子的个人信息，包括以下及其他相关活动：拍照，颁奖，
奖学金，奖品，新闻报道，分组名录，课题作业，美术作品，录音和录像，采访，学校公示，广告宣传材料。
同时我将同意我的孩子在相关活动中接受采访和媒体报道。
Semua biaya yang telah dibayarkan tidak dapat dikembalikan dan dipindah-tangankan dalam keadaan apapun.
All fees are non-refundable and non-transferrable under any circumstances.
已缴的报名费不許退款或转让。

Jakarta, ..........................................
Tanda Tangan / Signature,
Orang tua / Parent Orang tua / Parent - 2

.................................... ....................................

Document generated by
 TZU CHI SCHOOL
STUDENT'S HEALTH CARD
&
EMERGENCY INFORMATION FORM
STUDENT'S DATA

Name of student : James Nathan Winata Gender (M/F) : Male

Date of birth : 30 Oktober 2015 Blood type : B+
Jln. Husein Sastranegara
Ruko Duta Garden blok A1
Name of parents : Venny Kartika Kho Home address : no 3B Kelurahan Jurumudi,
Kecamatan Benda,
Tangerang
Home phone : 62215400780 Mobile phone : 6281289234360

NOMINATED EMERGENCY CONTACTS (persons in Jakarta known to the child - non parent)

1) Name : Venny Kartika Kho Relationship : Mother

Mobile phone : 6281289234360 Home phone : 62215400780
2) Name : Tan Hadi WInata Relationship : Father
Mobile phone : 6281296298897 Home phone : 62215400849

NAME OF DOCTOR & CLINIC

Name of doctor : dr. Andry Tangkilisan, Sp. A

Telephone :
Hospital/Clinic : RSIA Grand Family

INFORMATION WHICH MAY BE CRUCIAL IN THE HANDLING OF AN EMERGENCY

Physical handicap : No
Special requirements : No
Any long-term medication : Yes v No
Please list the name of medication, purpose & frequency (if the answer is "Yes" for the question above):

If there are any allergies, please fill in the table below:

Skin, food or drug allergies Reaction
No No
IMMUNIZATION RECORDS

Immunization Type Date Given

BCG 07/12/15
DPT/PT 06/01/16 30/05/17 30/01/16 30/05/16
Poliomyelitis (Polio) 06/11/15 30/05/16 06/01/16 30/05/17 30/01/16
Measles (campak) 18/10/16
MMR 21/11/17 01/06/18
HIB 30/01/16 30/05/17 12/04/16 30/06/16
Rubella 21/11/17 01/06/18
Typhoid (Tifus) 05/12/17
Infectious Hepatitis (Hepatitis) 30/10/15 07/12/15 29/04/16

What infectious diseases has your child ever suffered from?

Diseases Yes No Date Remarks
Measles (Campak) v
Chicken Pox (Cacar Air) v
Poliomyelitis (Polio) v
Infectious Hepatitis (Hepatitis) v
Typhoid (Thypus) v
Tonsilitis (Amandel) v
Whooping Cough (Batuk Rejan) v
Asthma (Asma) v
Convulsions (Kejang) v
Bronchitis v
Kidney Disease (Sakit Ginjal) v
Diabetes v
German Measles (Campak Jerman) v
Others v

Date of most recent Tetanus shot :

Does the child run high fever easily? : No
Has your child ever received treatment in a hospital emergency room? If so, why?
No
Has your child ever admitted to a hospital for surgery or as an inpatient? If so, why and when?
No
Do you have any concerns about your child's speech, communication, and understanding?
No
Please explain if there any limitations on physical activities.
No
 Questions Yes No
Does s/he have frequent earches/ear infections/hearing difficulties? v
Does s/he have eye trouble of any kind, squint/lazy eye/wear glasses? v
Does s/he have trouble with speech? v
Does s/he have any bad teeth? v
Does s/he have frequent colds, catarrh, nose bleed, sore throats, cough, wheezing or
v
breathlessness?
Does s/he tire very easily/get blue around the lips? v
Does s/he ever had fainting attacks, blackouts, or severe headache? v
Does s/he wet her/himself during the day/night? v
Does s/he have any digestion problems? v
Does s/he need any special diet for health reason? v
Does s/he have anything wrong with her/his bones or joints? v
Does s/he have any trouble with feet? v
Does s/he often have nightmares, night terrors, twitches, sleepwalking, etc? v
Is s/he a particular timid or anxious child/cries a lot for no reason/has frequent tantrums? v
Is s/he unhappy at school/a poor mixer/picked on alot by other children? v
Does s/he ever have educational or psychological testing? v

Please give explanation to any "Yes" answers for questions above.

If there are any health conditions of your child that is not stated in the list above, please explain in the
space provided below.

STATEMENT

I will inform the school of any change of these details. In the event of accident, if neither I nor my
emergency contacts can be notified, I authorize the Principal, or whoever s/he authorizes, to initiate any
necessary emergency medical procedures.

Jakarta, Parent's signature

(Name)