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EXHIBIT 3 <br />REQUEST TO RELEASE PRIVATE DATA FROM AN INDIVIDUAL <br />If you have a question about anything about this consent, or would like more explanation before <br />you sign it, 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 />I, , give my permission for the City of <br />Arden Hills to release data about me to <br />(name of other entity/person) as described in this consent. <br />1. The specific data I want the City of Arden Hills to release includes (explain data): <br />2. 1 understand that I have asked the City of Arden Hills to release the data. <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 other <br />entity/person) may not be the same and is dependent on laws or policies that apply to <br />(name of other entity/person). <br />[OPTIONAL] This permission to release expires (date) , 20_ at am/pm. <br />Signature <br />Signature of Parent/Legal Guardian <br />Date <br />Date <br />190435v1 <br />16 <br />