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Page 22 of 22 <br /> <br /> <br /> <br /> <br />City of Lake Elmo Data Practices Policy 01/03/2024 <br />You have the right to ask us to explain the consequences for giving your permission to release the data. You may withdraw your permission at any time. Withdrawing your permission will not affect the data that we have already released because we had your permission to release the data. If you have a question about anything on this form, or would like additional information or explanation, please contact Julie Johnson, City Clerk, 3880 Laverne Avenue North, Lake Elmo, Minnesota 55042; 651.747.3900 or jjohnson@lakeelmo.org, before signing. I, ____________________________________, give my permission for the City of Lake Elmo to release data about me to ________________________________ as described on this form. I understand that my decision to allow release of the data to _________________________________________ is voluntary. <br /> 1) The specific data that the City of Lake Elmo may release: ___________________________________________________________________________________________. 2) I understand the City of Lake Elmo wants to release the data for this reason: _________________________________________________________________________________________________. 3) I understand that although the data are classified as private at the City of Lake Elmo, the classification/treatment of the data at ___________________________ depends on laws or policies that apply to _____________________________. This authorization to release the data expires on _______________________________________________. <br />Individual data subject’s signature _____________________________________________________ <br />Date______________ <br />Parent/guardian’s signature [if necessary] _________________________________________________