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<br />Exhibit 5 <br />MU125\11\1101989.v1 <br /> <br />EXHIBIT 5 <br />NOTICE TO PERSONS UNDER AGE 18 <br /> <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 /> <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 /> <br />* Whether you are of sufficient age and maturity to explain the reasons and understand the <br />consequences; <br /> <br /> * Whether denying access may protect you from physical or emotional harm; <br /> <br /> * Whether there are reasonable grounds to support your reasons; and <br /> <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 /> <br /> <br />NOTICE GIVEN TO:_________________________________ DATE:___________________ <br /> <br />BY:__________________________________________________________________________ <br /> (Name) (Title) <br /> <br />REQUEST TO WITHHOLD INFORMATION <br /> <br />I request that the following information______________________________________________ <br />______________________________________________________________________________ <br /> <br />Be withheld from: ______________________________________________________________ <br /> <br />For these reasons:_______________________________________________________________ <br /> <br />Date:______________________ Print name: _________________________________________ <br />Signature: _____________________________________________________________________ <br />