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EXHIBIT 6 <br />CONSENT TO RELEASE PRIVATE DATA <br />I, , authorize the City of Mounds View ("City') to release the <br />(print name) <br />following private data about me: <br />to the following person(s) or entity(ies): <br />The person(s) or entity(ies) receiving the private data may use it only for the following purpose <br />or purposes: <br />This authorization is dated and expires on <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 <br />above -listed data to the persons identified in this release, and I waive any and all claims <br />against the City for the disclosure of private data about me in accordance with this <br />document. <br />Signature <br />Signature of parent or guardian <br />(if data subject is under 18 years of age) <br />IDENTITY VERIFIED BY: <br />❑ Witness: x <br />❑ Identification: Driver's License, State ID, Passport, <br />other: <br />❑ Comparison with signature on file <br />❑ Other: <br />Responsible Authority/Designee: <br />:;;�Exhibit 6 <br />n v99? Ryz PTA ML1125-D 1 \R50ULYZ <br />