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Krtki opis sytuacji |yciowej & & & & & & & & & & & & & & & & & & & & & & & & & & & & & & & & & & & & & & & & & & & & & & & & & & & & & & & & & & & & & & & & & & & & & & & & & & & & & & & & & & & & & & & & & & & & & & & & & & & & & & & & & & & & & & & & & & & & & & & & & & & & & & & & & & & & & & & & & & & & & & & & & & & & & & & & & & & & & & & & & & & & & & & & & & & & & & & & & & & & & & & & & & & & & & & & & & & & & & & & & & & & & & & & & & & & & & & & & & & & & & & & & & & & & & & & & & & & & & & & & & & & & & & & & & & & & & & & & & & & & & & & & & & & & & & & & & & & & & & & & & & & & & & & & & & & & & & & & & & & & & & & & Prosz zaznaczy, ktre z poni|szych kryteriw dotycz podopiecznego: mieszka samotnie miesiczny dochd nie przekracza kwoty 1.084 zB jest przeBNtvx ( f p r * 4 V . l ^r`ƿ|qhhCJaJh.hy0CJ aJ ,jh.hy0CJ UaJ mHnHtHuh.CJ aJ hJ.UhCJaJhZ7hCJaJ hZ7hhh5CJaJhh5 h^&5hZ7h5hh5CJ aJ hZ7h5CJ aJ *vx* 0 0b0&$a$gd & Fdgddgddgddhgd$a$gdwlekle lub ci|ko chory posiada orzeczenie o niepeBnosprawno[ci w stopniu umiarkowanym lub znacznym w cigu ostatnich 2 miesicy ucierpiaB w wyniku nagBego zdarzenia losowego, na skutek ktrego straciB zdolno[ samodzielnego funkcjonowania  O[wiadczam, |e podane przeze mnie informacje s zgodne z obecnym stanem faktycznym, a dane w nich zawarte s kompletne i prawdziwe. O[wiadczam, |e zapoznaBem si z Regulaminem [wiadczenia usBug teleopieki w ramach Projektu Przyjazni Seniorom i zobowizuj si do jego przestrzegania. Na podstawie ustawy z dnia 29 sierpnia 1997 art. 25, o ochronie danych osobowych (Dz.U.2002.101.926 z pzn.zm) upowa|niam Fundacj Innowacji Wspierajcych Samodzielno[ NIEZALE{NI, z siedzib w Sopocie, do przetwarzania zgromadzonych danych osobowych w celu przeprowadzenia postpowania kwalifikujcego do projektu Przyjazni Seniorom. & & & & & & & & & & & & & & & & & & & & & & & & & & & & & & & & & & & & & & & & & & & & & & & & & & & & & & & & & & Miejscowo[, data Czytelny podpis         `$& 4DFǼ~k~X~~$j6chCHh2CUmHnHtHu$jhCHh2CUmHnHtHuh2Cjh2CUmHnHtHuh/}jh/}Uh.hzCJaJh.hCJaJhCJaJhp hCJaJh.h.CJaJhh.CJaJh.CJaJhCJaJhhCJaJh2CCJaJ"&F dgdz d`gd. dgd.$a$gd.21h:p.. 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