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EXHIBIT 3 continued <br /> REQUEST TO RELEASE PRIVATE DATA FROM GOVERNMENT <br /> Explanation of your rights: <br /> • You have the right to choose what data we release. This means you can let us release all of the data, some of <br /> the data, or none of the data listed in this consent. Before you give permission to release the data, we <br /> encourage you to review the data listed in this consent. <br /> • You have the right to let us release the data to all, some, or none of the persons or entities listed on this form. <br /> This means you can choose which entities or persons may receive the data and what data they may receive. <br /> • You have the right to ask us to explain the consequences for giving your permission to release the data. <br /> • You may withdraw your permission at any time. Withdrawing your permission will not affect the data that we <br /> have already released because we had your permission to release the data. <br /> • You may give us permission to discuss the data released by this form with the outside entity. If you choose not <br /> to give us permission, you may still allow us to release the data. <br /> If you have a question about anything about this consent, or would like more explanation before you sign it, <br /> please contact the Responsible Authority(or Designee): <br /> City Clerk <br /> City of Arden Hills <br /> 1245 W Highway 96, Arden Hills MN 55112 <br /> 651-792-7811 <br /> PERMISSION TO RELEASE <br /> I , give my permission for the City of Arden Hills to <br /> release data about me to (name of other <br /> entity/person) as described in this consent. I understand that my decision to allow release of the data <br /> to (name of other entity/person) is voluntary. <br /> 1. The specific data that the City of Arden Hills may release to (name <br /> of other entity/person) are (explain data): <br /> 2. 1 understand the City of Arden Hills wants to release the data for this reason (explain reason): <br /> 3. 1 understand that although the data are classified as private at the City of Arden Hills, the <br /> classification/treatment of the data at (name of <br /> other entity/person) may not be the same and is dependent on laws or policies that apply to <br /> (name of other entity/person). [INCLUDE OTHER <br /> CONSEQUENCES] <br /> 4. [OPTIONAL]. I give the City of Arden Hills permission to discuss the data released by this consent with <br /> (name of other entity/person). <br /> [OPTIONAL] This permission to release expires (date) , 20 at am/pm. <br /> Signature Date <br /> Signature of Parent/Legal Guardian Date <br /> 190435v1 <br /> 15 <br />