GSK Science in the SummerTM Parent/Guardian Acceptance Form

PARENT/GUARDIAN ACCEPTANCE OF PROGRAM GUIDELINES

I understand that student registrations will be accepted in the order they are received. I MUST sign and submit this form for my child to participate in the program. If my child cannot attend the session, I will contact program administrators to cancel. I give permission for my child to participate in the GSK Science in the Summer™ program and my signature below indicates my acceptance of the following:

My child must:

• arrive promptly at the assigned time

• wear all safety equipment, including safety glasses (provided by GSK)

• wear closed toe shoes (sneakers are recommended).

I hereby warrant that I am the parent or legal guardian of the below said child and that I am eighteen years old or more and competent to contract in my own name. I have read, understood & agree to the GSK Science in the Summer general policies. This release is binding on me, my child, and our heirs, legal reprentatives, and assigns. I understand that while both the class and home activities are designed to be safe, neither the host organization, nor the teacher, nor the volunteer, nor the GSK Science in the Summer Program Administrator, nor GlaxoSmithKline LLC (“GSK”), warrants, or can guarantee that an accident will not occur. In consideration for my child’s participation in the GSK Science in the Summer program, I agree not to initiate any action against the host organization, teacher, volunteer, GSK, its parent company, subsidiaries, and affiliated companies, and their respective officers, directors, employees, agents, licensees, successors, assignees, permittees, heirs, executors, and administrators, and to forever refrain from instituting any claims, causes of action, suits or proceedings of any kind for any injury or damage resulting from participation in the GSK Science in the Summer program or from use of the take-home materials after the conclusion of the program. I hereby understand and consent to the conditions of the GSK Science in the Summer program as described above.

I hereby certify that I am the parent or guardian of

My electronic signature is the legal equivalent of my manual signature and I consent to be legally bound by my electronic signature below.

Parent/Guardian Signature