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Exhibit 5 <br />489828v3 DTA MU125-11 <br />EXHIBIT 5 <br />NOTICE TO PERSONS UNDER AGE 18 <br />Some of the information you are asked to provide is classified as private under State law. <br />You have the right to request that some or all of the information not be given to one or both of <br />your parents/legal guardians. Please complete the form below if you wish to have information <br />withheld. <br />Your request does not automatically mean that the information will be withheld. State <br />law requires the City to determine if honoring the request would be in your best interest. The <br />City is required to consider: <br />Whether you are of sufficient age and maturity to explain the reasons and understand <br />the consequences; <br />Whether denying access may protect you from physical or emotional harm; <br />Whether there are reasonable grounds to support your reasons; and <br />Whether the data concerns medical, dental, or other health service provided under <br />Minnesota Statutes Sections 144.341 to 144.347. If so, the data may be released only if <br />failure to inform the parent would seriously jeopardize your health. <br />NOTICE GIVEN TO:_________________________________ DATE:___________________ <br />BY:__________________________________________________________________________ <br />Name) (Title) <br />REQUEST TO WITHHOLD INFORMATION <br />I request that the following information______________________________________________ <br />Be withheld from: ______________________________________________________________ <br />For these reasons:_______________________________________________________________ <br />Date:______________________ Print name: _________________________________________ <br />Signature: _____________________________________________________________________