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<br />Exhibit 6 <br />MU125\11\850810.v2 <br />EXHIBIT 6 <br />CONSENT TO RELEASE PRIVATE DATA <br /> <br />I, , authorize the City of Mounds View (“City”) to release the <br /> (print name) <br /> following private data about me: <br />______________________________________________________________________________ <br />______________________________________________________________________________ <br /> <br />to the following person(s) or entity(ies): <br />______________________________________________________________________________ <br />______________________________________________________________________________ <br /> <br />The person(s) or entity(ies) receiving the private data may use it only for the following purpose <br />or purposes: <br />______________________________________________________________________________ <br />______________________________________________________________________________ <br /> <br />This authorization is dated _________________and expires on___________________________ <br /> <br />I understand that my records are protected under state privacy regulations and cannot be <br />disclosed without my written consent unless otherwise provided for by law. I also <br />understand that I may cancel this consent at any time prior to the information being <br />released and that in any event this consent expires automatically 90 days after signing. By <br />signing this document, I give my full and voluntary consent to the City to release the above- <br />listed data to the persons identified in this release, and I waive any and all claims against <br />the City for the disclosure of private data about me in accordance with this document. <br /> <br />___________________________________ <br />Signature <br /> <br />___________________________________ <br />Signature of parent or guardian <br />(if data subject is under 18 years of age) <br /> <br />IDENTITY VERIFIED BY: <br /> <br /> Witness: x______________________________ <br /> Identification: Driver’s License, State ID, Passport, <br />other:__________________________________ <br /> Comparison with signature on file <br /> Other:__________________________________ <br /> <br />Responsible Authority/Designee: ___________________________________________ <br />