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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 or <br /> 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 understand <br /> that I may cancel this consent at any time prior to the information being released and that <br /> in any event this consent expires automatically 90 days after signing. By signing this <br /> document,I give my full and voluntary consent to the City to release the above-listed data to <br /> the persons identified in this release, and I waive any and all claims against the City for the <br /> disclosure of private data about me in accordance with this 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 />