Designated Contact

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BENEFICIARY INFORMATION

Beneficiary Name
Legal Representative (if applicable)

DESIGNATED CONTACT

1. Authorization

I hereby designate the individual named in this document as an authorized contact for the purposes specified below.

2. Purpose

Purpose

3. Designated Contact

Name
Address

4. Right to Revoke

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.

5. Authorization Validity

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.

6. Contact Information for Questions

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]

7. Acknowledgment

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.

Clear Signature

Additional Notes

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.

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