Parental Permission - Youth Ambassadors

Mental Health Ambassador Program

This form must be completed by a parent or legal guardian for all participants between the ages of 13 and 17. Please read all sections carefully before signing.

The minor’s interest form must also be submitted separately.

1. Minor Participant Information

Minor’s First Name(Required)

Minor’s Last Name(Required)

Minor’s Date of Birth(Required)

Participant must be between 13 and 17 years of age.

Minor’s Age(Required)

Minor’s Email Address

Optional

2. Parent / Legal Guardian Information

Guardian First Name(Required)

Guardian Last Name(Required)

Relationship to Minor(Required)

Guardian Email Address(Required)

Guardian Phone Number(Required)

3. Rights, Likeness & Compensation

Please read this section carefully before signing.

Grant of Rights — Name & Likeness: You hereby grant to Community, Serve Us and its parent company, Studio Kula by Busko, Allen, Bodosi & Stefuliga LLC (“Studio Kula”) (collectively, “the Company”), the irrevocable, perpetual, worldwide, royalty-free right and license to use your minor child’s name, image, voice, likeness, personal story, and any content they contribute — in any and all media, now known or hereafter developed — for purposes including but not limited to: community platform content, streaming video, social media, promotional and marketing materials, immersive or VR experiences, news and insights content, and any other use connected to the Community, Serve Us platform and its associated seasons, campaigns, or initiatives.

Ownership: All content created by, featuring, or derived from your minor child’s participation is and shall remain the sole and exclusive intellectual property of Community, Serve Us and Studio Kula by Busko, Allen, Bodosi & Stefuliga LLC (“Studio Kula”). Neither you nor your minor child will hold, claim, or assert any ownership interest in such content, now or at any point in the future. This grant of rights is permanent and cannot be revoked.

No Compensation: Participation is entirely voluntary and unpaid. Neither you nor your minor child will receive, nor are entitled to claim, any monetary compensation, royalties, residuals, or other remuneration of any kind for your child’s participation, contributions, likeness, story, or any content created in connection with this program.

Important — Social Media Responsibility: While Community, Serve Us employs human and AI-assisted moderation and maintains a separate youth environment, we are not responsible for governing your child’s personal social media interactions or accounts. Activity on third-party platforms remains entirely the responsibility of the parent or legal guardian.

4. Consent Acknowledgements

Please read and check each box. All are required to submit this form.

Permission for Filmed Content, Platform & Social Media(Required)

I have read and understood the Scope of Permission and grant my minor child permission to participate in filmed roundtable episodes and video content; have that content streamed on the Community, Serve Us platform, YouTube channel, and social media channels; express their opinions on social media on behalf of this season and Community, Serve Us; and participate in the to-be-launched Youth Community including crowdsourcing tools, forums, and idea-sharing features.

Social Media Responsibility(Required)

I understand that Community, Serve Us maintains human and AI-assisted moderation on its platform and separates youth and adult interactions, but I acknowledge that social media activity outside the platform remains my responsibility as the parent or legal guardian.

Non-Clinical Participation(Required)

I understand that participation is voluntary and non-clinical in nature. Community, Serve Us is a community engagement platform, not a mental health treatment or clinical service provider.

Rights, Likeness & No Compensation(Required)

I grant Community, Serve Us and Studio Kula by Busko, Allen, Bodosi & Stefuliga LLC the irrevocable, perpetual right to use my minor child’s name, image, voice, likeness, and story in any media connected to the platform. All content created through my child’s participation is the sole property of Community, Serve Us and Studio Kula. Neither I nor my child may claim ownership now or in the future, and no compensation of any kind will be provided.

Digital Signature Acknowledgement(Required)

I acknowledge that I am providing a digital signature on this form, which carries the same legal intent as a handwritten signature. I confirm I am the parent or legal guardian of the minor named above and am authorized to grant this permission.

VR / Immersive Storytelling — Additional Consent (Optional)

VR / Avatar Consent (optional — check only if your child wishes to participate in the immersive storytelling experience): I grant permission for my child’s personal mental health story to be told through Community, Serve Us’s AI-assisted immersive environment, including the creation and use of a digital avatar rendered with my child’s likeness. I understand this content may be viewed by users of the Community, Serve Us platform and associated channels.

5. Identity Verification

Please upload a photo of one of the following: Driver’s License, State/Government-Issued ID, or Passport. Your document will be used solely for identity verification and stored securely.

Upload ID Document(Required)

Accepted file types: jpg, jpeg, png, webp, heic, pdf, Max. file size: 10 MB.

Accepted: JPG, PNG, WEBP, HEIC, PDF · Max 10MB

6. Digital Signature

By typing your full legal name and today’s date below, you confirm all information is accurate and that you are granting the permissions described above. This constitutes your digital signature.

Full Legal Name (Digital Signature)(Required)

Typing your name here confirms your digital signature and legal consent.

Date(Required)

Name

This field is for validation purposes and should be left unchanged.