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190435v1 <br />15 <br />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 /> <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 /> <br />City Clerk <br />City of Arden Hills <br />1245 W Highway 96, Arden Hills MN 55112 <br />651-792-7811 <br />_______________________________________________________________________________________________________________ <br />PERMISSION TO RELEASE <br /> <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 /> <br />2. I understand the City of Arden Hills wants to release the data for this reason (explain reason): <br /> <br /> <br />3. I 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 /> <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 /> <br />[OPTIONAL] This permission to release expires (date) _______________, 20__ at _____ am/pm. <br />__________________________________________________ _______________________ <br /> Signature Date <br />__________________________________________________ _______________________ <br /> Signature of Parent/Legal Guardian Date