Informed Consent Release of Information

  • Explanation of your Rights and Permission to Release

     

    If you have a question regarding this consent, or would like more explanation before you sign, please contact:

    Jessica Mead

    City Clerk

    507-449-9898

    jmead@cityofluverne.org

Permission to Release

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  • I give my permission for the City of Luverne, MN to release data about me or my organization to the below named individual, organization or entity as described in this consent.

  • 2.      I understand that the records described above are protected under state and/or federal privacy regulations and cannot be disclosed without my written consent unless otherwise provided for by law.

    3.      I understand I have asked the City of Luverne, MN to release the data.

    4.      I understand that although the data are classified as private at the City of Luverne, MN, the classification/treatment of the data at the City of Luverne, MN may not be the same and is dependent on laws or policies that apply to me or the organization/entity listed above, if applicable.

  • I also understand that I may cancel this consent at any time prior to the information being released by notifying City Clerk Jessica Mead in writing and that, in any event, this consent form expires automatically on December 31.  I also affirm that I am an authorized signer for the above-named organization/entity, if applicable.

  • Date Selection