Zgoda Na Wyjazd Dziecka

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..............................., dnia ..................... r.

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

OWIADCZENIE

My, niej podpisani owiadczamy, e wyraamy zgod na wyjazd naszego dziecka

syn/crka ..........................................................................................................................
PESEL ..............................................................................................................................
posiadajcego paszport numer ........................................................................................ ,
do ..................................................................................................................................... ,
w terminie od ............................................ do .................................................................
pod opiek ........................................................................................................................
PESEL ..............................................................................................................................
posiadajcego paszport numer .........................................................................................
oraz na podejmowanie przez osob, pod ktrej opiek bdzie pozostawao nasze
dziecko w trakcie tego pobytu, wszelkich decyzji w sprawie opieki medycznej.

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

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