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Page 22 of 22 <br />You have the right to ask us to explain the consequences for giving your permission to release <br />the data. You may withdraw your permission at any time. Withdrawing your permission <br />will not affect the data that we have already released because we had your permission to <br />release the data. <br />If you have a question about anything on this form, or would like additional information or <br />explanation, please contact Julie Johnson, City Clerk, 3880 Laverne Avenue North, Lake Elmo, <br />Minnesota 55042; 651.747.3900 orijohnson0lakeelmo.or , before signing. <br />1, , give my permission for the City of Lake Elmo to release <br />data about me to as described on this form. I understand that <br />my decision to allow release of the data to is voluntary. <br />1) The specific <br />data that <br />the City of <br />Lake <br />Elmo may <br />release: <br />2) 1 understand the <br />City of Lake <br />Elmo wants to <br />release <br />the data for this <br />I <br />reason: <br />3) 1 understand that although the data are classified as private at the City of Lake Elmo, <br />the classification/treatment of the data at depends on laws or <br />policies that apply to This authorization to release the data <br />expires on I <br />Individual data subject's signature <br />Date�_ <br />Parent/guardian's signature [if necessary] <br />