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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 law <br /> requires the City to determine if honoring the request would be in your best interest. The City is <br /> required to consider: <br /> * Whether you are of sufficient age and maturity to explain the reasons and understand the <br /> 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: <br /> li�Exhlblt 5 <br />