Laserfiche WebLink
Page 22 of 22 <br />C i t y o f L a k e E l m o D a t a P r a c t i c e s P o l i c y 2026 <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 or jjohnson@lakeelmo.org, before signing. <br />I, ____________________________________, 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 data that the City of Lake Elmo may release: <br />___________________________________________________________________________________________. <br />2) I understand the City of Lake Elmo wants to release the data for this reason: <br />_________________________________________________________________________________________________. <br />3) I 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 _______________________________________________. <br />Individual data subject’s signature _____________________________________________________ <br />Date______________ <br />Parent/guardian’s signature [if necessary] _________________________________________________