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406-F: Public & Private Personnel Data

 Consent to Release Data – Request from an Individual

An individual asks the government entity to release his/her private data to an outside entity or person.  Because the entity does not have statutory authority to release the data, it must get the individual’s written informed consent. 

Explanation of Your Rights 

If you have a question about anything on this form, or would like more explanation, please talk to
the Director of Human Resources at 763-792-6009 before you sign it.

I, _____________________________________, give my permission for Centennial School District
    [name of individual data subject]                     

to release data about me to __________________________________as described on this form.
                [name of other entity or person]  

1.        The specific data I want Centennial School District to release ________________________. 

                                             [explanation of data]
2.     I understand that I have asked Centennial School District to release the data.
3.     I understand that although the data are classified as private at Centennial School District, the
        classification/treatment of the data at Centennial School District depends on laws or 
        policies that apply to Centennial School District. 

    This authorization to release expires _____________________. 
                        [date/time of expiration]
    Individual data subject’s signature ____________________________________ Date______________ 
    Parent/guardian’s signature [if needed] ________________________________ Date______________