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190435v1 <br />18 <br />Deleted: 1¶ <br />¶ <br />Exhibit 6 <br />NOTICE TO PERSONS UNDER AGE OF 18 <br />Some of the information you are asked to provide is classified as private under state law. You <br />have the right to request that some of all of the information not be given to one or both of your <br />parents/legal guardians. Please complete the form below if you wish to have information withheld. <br />Your request does not automatically mean that the information will be withheld. State law requires <br />the City to determine if honoring the request would be in your best interest. The City is required to <br />consider: <br />• Whether you are of sufficient age and maturity to explain the reasons and understand the <br />consequences, <br />• Whether denying access may protect you from physical or emotional harm, <br />• Whether there is reasonable grounds to support your reasons, and <br />• Whether the data concerns medical, dental, or other health services provided under <br />Minnesota Statutes § 144.341 to 144.347. If so, the data may be released only if failure to <br />inform the parent would seriously jeopardize your health. <br />NOTICE GIVEN To: ______________________ DATE: <br />BY:_________________________ ___________________________ <br />(name) (title) <br />REQUEST TO WITHHOLD INFORMATION <br />I request that the following information: <br /> <br /> <br /> <br />Be withheld from: <br /> <br />For these reasons: <br /> <br /> <br /> <br />Date: ______________ Print Name:______________________ Signature:____________________________ <br /> <br />