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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 /> Be withheld from: <br /> For these reasons: <br /> Date: Print Name: Signature: <br /> 190435v1 <br /> 18 <br />