I hereby designate the individual named in this document as an authorized contact for the purposes specified below.
I understand that I have the right to revoke this authorization at any time by providing written notice to Knospe-Lerncenter GmbH. Revocation will not affect any actions taken before the receipt of the revocation.
This authorization will remain in effect until discharge from Knospe-Lerncenter GmbH, unless I request an earlier expiration date here:
Thereafter, this authorization becomes null and void. I understand that I have a right to receive a copy of this authorization.
If you have questions about this authorization or need to revoke it, please contact:
Knospe-Lerncenter GmbH Georgstr 2, 31675 Bückeburg, Deutschland Phone: +49 5722 9098399 Email: [email protected]
I have read and understood this authorization form. I understand that I have a right to receive a copy of this authorization.
By signing below, I agree to the terms and conditions outlined above.
Please be aware that authorizing a contact for release or emergency purposes does not grant Knospe-Lerncenter GmbH permission to disclose any personal or health information about the beneficiary to the authorized contact. Any such disclosure would require a separate Authorization to Release Information.
