ࡱ> >@=%bjbj4*yyJJ40            $B0E0  u     p//h0h(>(00J+ u:__________, 24 February 2022 Zgoda na wyjazd dziecka z Ukrainy Ja, ni|ej podpisany: ______________________________________, obywatel Ukrainy, jako przedstawiciel ustawowy maBoletniego: ______________________________________ - obywatela Ukrainy, o[wiadczam, |e wyra|am zgod na przejazd przez granic (rwnie| na wielokrotne przekraczanie granicy) z Ukrainy do Polski i z powrotem od 24 lutego 2022 roku do 31 grudnia 2022 roku mojego maBoletniego dziecka: ______________________________________, urodzonego dnia ________________ w miejscowo[ci ______________________, pod samodzieln opiek: __________________________________, obywatelki Ukrainy, urodzonej dnia ______________________, legitymujcej si paszportem/kart pobytu numer __________________________________, ktr jednocze[nie upowa|niam: do uzyskiwania wszelkich dokumentw podr|nych w tym paszportu, wiz, pozwoleD i wszelkich innych, do podejmowania wszelkich decyzji dotyczcych |ycia i/ zdrowia mojego dziecka w okresie wyjazdu, nie wyBczajc spraw dotyczcych ewentualnego leczenia mojego maBoletniego dziecka, wyboru [rodka i sposobu transportu, drogi oraz miejsca pobytu.  Consent to a child leaving Ukraine I, the undersigned: ______________________________________, citizen of Ukraine, be8:<JNR^`n  ( * , 4 6 R T d f ~     * , 6 : > @ P R \ ^ l n r ܿ܉h' h' 0JB*ph###h' h' 0JB*ph###!h' h' 0JB*mHph###sHh' h' B*phh' h' 0JB*ph###h' h' 0J5B*\ph###h' h' 0J5B*\ph###hqOJQJ^Jh' OJQJ^J6:<>, , $ VXd$Ifgd' $$9DIf[$\$a$gd' $$9DIf[$\$a$gd' dgd' $da$gd' r t ~  & 2 : H V b j l x z  < T   ( * , > @ H z ǼǼǼh' h' 0J5B*\ph###h' h' 0J5B*\ph###h' h' B*phh' h' 0JB*ph###h' h' 0JB*ph###h' h' 0JB*ph###!h' h' 0JB*mH ph###sH = "$(*.0HJV^`bh~ͽqdS!h' h' 0JB*mH ph###sH h' h' 0JB*ph'h' h' 0J5B*\mHph###sH'h' h' 0J5B*\mHph###sHh' h' 0J5B*\ph###'h' h' 0J5B*\mH ph###sH h' h' 0J5B*\ph###h' h' B*phh' h' 0JB*ph###h' h' 0JB*ph###h' h' 0JB*ph### ",DFXZhj&(@BRT`bz|  ͽ!h;0J5B*\mH ph###sH h' h' 0J5B*\ph###h' h' OJQJ^Jh' h' B*phh' h' 0JB*ph###h' h' 0JB*ph###D $>DTVX~VBDr P (!*!,!Z!\!!!!!"ɺɺɺtffɺ뺩ɺhrU0JB*mH ph###sH h;0JB*mH ph###sH 'h' h' 0J5B*\mH ph###sH U!h' h' 0JB*mH ph###sH !h' h' 0JB*mH ph###sH h' h' B*mH phsH !h' h' 0JB*mH ph###sH !h;0J5B*\mH ph###sH 'h' h' 0J5B*\mH ph###sH (ing a statutory representative of the minor: ______________________________________ - citizen of Ukraine, represent that I consent, to the crossing of the border (to the crossing of the border multiple times as well), from Ukraine to Poland and back, from 24 February 2022 to 31 December 2022, by my minor child: ______________________________________, born on ________________ in ______________________, under the sole care of: __________________________________, citizen of Ukraine, born on ______________________, holder of the passport/residence card no. __________________________________, whom I also authorise to: obtain all travel documents, including passports, visas, permits, and all other travel documents; make all decisions concerning my child s life and health during the journey, including all matters concerning possible medical treatment of my minor child; choose the means of transport and manner of travelling, the route, and the place of accommodation.  ,!\!!"%%%%UK dgd' kd$$IfF0% t0644 lapyt' d$Ifgd' $$9DIf[$\$a$gd' "N"P"X"b""""""j##:$$$%%%ƻteT h' h' OJQJ^JmH sH h' h' B*mH phsH h;0JB*mH ph###sH !h' h' 0JB*mH ph###sH 'h' h' 0J5B*\mHph###sH'h' h' 0J5B*\mH ph###sH h' h' B*phh' h' 0JB*ph###h' h' 0JB*ph###!h' h' 0JB*mH ph###sH h;0JB*mH ph###sH 21h:p' . A!n"n#n$n% $$If!vh#v:V F t065pyt' j 666666666vvvvvvvvv666666>6666666666666666666666666666666666666666666666666hH6666666666666666666666666666666666666666666666666666666666666666662 0@P`p2( 0@P`p 0@P`p 0@P`p 0@P`p 0@P`p 0@P`p8XV~ OJPJQJ_HmHnHsHtHN`N Normalny dCJ_HaJmHsHtH JA J Domy[lna czcionka akapituPi@P 0 Standardowy4 l4a ,k , 0 Bez listy ~~ ' Tabela - Siatka7:V0 d^O^ ' paragraphddd[$\$CJOJPJQJ^JaJtH2o2 ' normaltextrun2o!2 ' spellingerroro1 ' eopBoAB ' unsupportedobjecttextPK![Content_Types].xmlN0EH-J@%ǎǢ|ș$زULTB l,3;rØJB+$G]7O٭VFMG.|H" rxx5aKFXKS1,G-TNz b1UB8;^e9nNӨZ=dwqŷ7͠iލ.éIB'º;z~ݡOCQJ ˦96M .*!ޞovngUVo UYC<7^S*C0ױDzRA#8ꍉU47U6K|Ptu̹'Yv@~ !E1 ۰Nh4Of**byp/36Ĵ^NhwQV5nhϿ~Tڲ7ac$bL.Xܢ5w97[ Cֳ6|O(c5c4-h܇EMnUD !~`ϘJ0A?My71e1ۭ.Ѣ-4RUn{uSLɟ)nL \BuB7Ji\Cbw@m/k_֜aΒjFHP؏T,مdf|,Yd̬#r@PU(T7$ow<缂Frz:Y'[`߇@ST滪7_ǬFQ Zyٿ ڎ`rPh1,QWIDANT~AoE)C3`]dm2iVֵ褽Vl *r "% % 8@0(  B S  ?EJKN9:?%+.RSntBEV(mn;\^mn~x1( x1w mnx1x1|%x1Y0x1x1PBMQmn}c`mn@LfmnhimnTvkmn%&|lmnlmnmx1mnFox1/vtx1YfN}x1qrU' ;@ tttt@ UnknownG*Ax Times New Roman5Symbol3. *Cx Arial7.@CalibriA$BCambria Math"1;)BB!nn0JQHX  $P' 2!xx SylwiaSylwiaOh+'0T    (4<DLSylwiaNormalSylwia3Microsoft Office Word@_@.@N/B՜.+,0 hp|  HP  Tytu  !"#$%&'()*+,./012346789:;<?Root Entry F3/AData 1TableWordDocument4*SummaryInformation(-DocumentSummaryInformation85CompObj{  F)Dokument programu Microsoft Word 972003 MSWordDocWord.Document.89q