Appendix 4 Consent Form for Minors

Young Women In Bio visit to JLABS @ SSF

November 7, 2017

Confidential Information

As part of your participation in Young Women In Bio., you will be visiting Johnson & Johnson Innovation, JLABS @ SSF and interacting with employees of JLABS and companies who license space at JLABS known as Licensees. In connection with those activities, you may hear, see, or otherwise obtain certain information relating to JLABS or its Licensees (collectively, the Company) which they consider confidential and proprietary (“Confidential Information”).

You agree to maintain in confidence all Confidential Information and not to disclose it to any third party without the express written consent of the relevant Company, to be given or withheld in the Company’s absolute discretion. You agree to take all necessary and reasonable precautions to prevent the disclosure of Confidential Information to any unauthorized third parties. Any papers, reports, or summaries that you prepare of your visit may not include Confidential Information.

Confidential Information may not be used for any purpose other than for your visit without the express written consent of the relevant Company, to be given or withheld in the Company’s absolute discretion.

You agree that any presentation you make or information you disclose as part of your participation in the visit will not include any Confidential Information.

Consent and Release

You also understand that your visit may be filmed and/or recorded and further understand that if you attend this visit your picture, likeness, or voice, or any or all of them, or portion of them, may appear in a still photograph, advertisement or in the general media as a results of your attendance in this visit with no compensation to you.

You hereby consent to the use of your picture, likeness, or voice as mentioned in the preceding paragraph and for any lawful purpose throughout the world.

You hereby fully release and forever discharge JLABS, J&J Innovation, Johnson & Johnson including its affiliates and any of their respective officers, directors, employees, agents or representatives from any and all claims, actions, lawsuits or damages of any type for any claims arising from any use whether lawful or unlawful, of your child’s picture, likeness or voice as recorded during the visit.

You also understand that Young Women in Bio is organizing this field trip and will be responsible for the visit. You must follow any directions and instructions provide by Leah Makley or JLABS personnel during this visit.

Prior to your visit, please make sure the form is filled out completely and signed and, if you are a minor, is signed by your parent or guardian.

Participant’s Name:

Signature: ______(REQUIRED)

Parent/Guardian’s Name: ______

Parent/Guardian’s Signature: ______

Emergency Contact: ______Phone Number: ______

Please return this form in its entirety (3 pages) to your ______representative.

PARENTAL PERMISSION FOR FIELD TRIP

I,______certify that I am the parent, guardian, or

(Print name of parent, guardian, or custodian)

custodian of ______. I authorize and consent for my child to

(Print name of minor)

participate in a field trip organized by ______as part of the Summer internship program to JLABS SSF on [DATE] . Transportation will be provided by students and/or their guardians.

Please list any special health concerns (example – asthma, bee sting allergy, etc.)

The following persons should be contacted first in case of an emergency:

at ______

(Parent, Guardian, Emergency Contact – Please Print) (Phone Number – home)

(Phone Number – work

(Phone Number – cell)

Second Emergency Contact:

at ______

(Please Print) (Phone Number – home)

(Phone Number – work)

(Phone Number – cell)