Transportation Release

BENEFICIARY INFORMATION

Beneficiary Name

First

Last

Date of Birth

Legal Representative (if applicable)

First

Last

TRANSPORATION RELEASE

1. Authorization

I hereby authorize Knospe-Lerncenter GmbH to transport the beneficiary for the purposes and via the transportation modes described.

2. Purposes

Purposes

Attending therapeutic sessions
Participating in off-site activities as part of the therapy
Other

3. Transportation Modes

Purposes (copy)

Vehicle (company or employee car, van, etc.)
Public transportation (bus, tram, train, etc.)

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. If I revoke this authorization, I understand that certain therapeutic activities requiring transportation may not be available.

5. Authorization Validity

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

Expiration

Optional Expiration Date

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.

Signature of Beneficiary or Legal Representative

Clear Signature

Date

Section Divider

Please be aware that a separate Off-Site Release may be required for therapeutic activities during transport or at off-site locations.