Off-Site Release

Please enable JavaScript in your browser to complete this form.

BENEFICIARY INFORMATION

Beneficiary Name
Legal Representative (if applicable)

OFF-SITE RELEASE

1. Authorization

I hereby authorize Knospe-Lerncenter GmbH to conduct off-site sessions with the beneficiary at the locations described.

2. Locations

Locations

3. 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. If I revoke this authorization, I understand that certain therapeutic activities requiring off-site locations may not be available.

3. Authorization Validity

This authorization will remain in effect indefinitely, unless I request an earlier expiration date here:

Optional Expiration Date

Thereafter, this authorization becomes null and void. I understand that I have a right to receive a copy of this authorization.

4. 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]

5. 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.

Additional Notes

Please be aware that a separate Transportation Release may be required for transport to/from off-site locations or for transport without a therapeutic objective.

Team Portal

Please enable JavaScript in your browser to complete this form.
Remember me