Please sign, notarize and return this Release no later than [insert day/date] to:, sending original to Moxie Chic, 170 East 83rd Street, 6F, NY NY 10028.


I, _____________________________________, being duly sworn, depose and say:


That I am a parent/legal guardian of winner _____________________, a minor and that I hereby agree that such minor and I shall be bound by all terms of this agreement.


As of October 11, 2020 my child/ward was  ____ years old.  My child/ward’s birth date is _______________.  My child/ward resides at (include city, state, and zip): 



I am submitting this Affidavit to Moxie Chic with the understanding that it will be relied upon in connection with my child/ward’s entry in the Young Artist Design Contest (“entry” or the “Design”) sponsored by Moxie Chic (i.e., Moxified Designs LLC) (the “Sponsor”) and that my child/ward accepts being selected as the winner in the Contest.


I represent that my child/ward has complied with all the rules and regulations of this contest, that my child/ward was between the ages of five (5) and sixteen (16) as of October 11, 2020 and is a resident of the 50 United States or the District of Columbia.  In addition, I certify that the information contained in my child/ward’s entry is true and that my child/ward and I have the right to enter into this Agreement. I certify that my child/ward has perpetrated no fraud or deception in connection with her entry. If any statement made by me in this Affidavit is false, then, in addition to any other remedies that may be taken against me, I agree to return to the Sponsor and their respective subsidiaries, affiliates, or advertising and promotional agencies any prize awarded to my child/ward, or its cash equivalent.


I understand that my child/ward’s prize includes featuring the Design on and Moxie Chic’s social media channels, having Moxie Chic convert the Design into a t-shirt design (conversion may require changes to design as determined in Sponsor’s sole discretion) to be sold on, with 100% of profits being donated to Girls, Inc. for a period of time determined by Sponsor in its sole discretion and that my child/ward shall not be entitled to any monetary compensation for winning the Contest and will not receive any of the proceeds from the sale(s) of the shirts bearing the Design.  

For good and valuable consideration: (i) I and my child/ward hereby irrevocably assign all right, title and interest in and to the Design and all intellectual property (including copyright) rights therein to Sponsor as well as the unqualified right to use the Design in Sponsor’s sole discretion, in whole or in part, throughout the world in all languages, to reproduce the Design in any medium now known or hereafter developed, to alter the Design and seek and obtain registration or other protection under copyright, trademark and any other applicable law, and appoint Sponsor as attorney-in-fact to execute any and all documents necessary or appropriate to accomplish such acts, which appointment is coupled with an interest and is irrevocable. (ii)  I and my child/ward hereby irrevocably waive and agree never to assert any and all “Moral Rights” (defined below) I or my child/ward may have in or with respect to the Design. Moral Rights mean any rights to claim authorship of any element of the Design, to object to or prevent any modification of the Design, to withdraw from circulation or control the publication or distribution of the Design, and any similar rights, existing under any law anywhere in the world.  I agree that neither I nor my child/ward will publish or publicly disseminate the Design, or portions thereof, in any way.  

My child/ward and I understand and acknowledge and hereby agree to be responsible for all federal, state and local taxes on my child/ward’s prize and understand that an IRS Form 1099 will be issued in the name of the recipient for the value of the prize. 


I hereby grant to the Sponsor, its respective subsidiaries and affiliates, their advertising and promotion agencies, and all other companies involved in the Contest, without limitation, permission and authority to use my child/ward’s name, city and state of residence, her contest entry including any and all elements thereof, and to use my child/ward’s voice, photograph and likeness for any advertising and promotion purposes in any and all media, without further compensation, except where prohibited by law. I understand my child/ward and I shall not have the right to inspect and/or approve such uses.


For good and valuable consideration for my child/ward receiving a prize in the Contest, I hereby release, discharge and absolve the Sponsor, its respective affiliates, subsidiaries, directors, officers, employees, agents and all others associated with the development and execution of this Contest from any and all actions, suits, claims and demands of any kind whatsoever, which I, my child/ward, my heirs, executors, administrators and assigns, had, now have or hereafter may have, by reason of any matter connected in any way with this Contest, including, but not limited to, the operation of this Contest, any warranty or representations, express or implied, relative to any prize, the awarding of any prize, and any action, claim or suit in connection with the Contest, including without limitation in connection with Sponsor creating and selling t-shirts bearing the Design. 

I, the undersigned, do hereby for myself, my heirs, executors, and assigns, release, remise and forever discharge and agree to indemnify and hold harmless individuals, officers, agents of Moxified Designs, LLC and Girls Inc. (all collectively “Releasees”), sanctioners, servants, employees of and from every claim, demand, action or right of action of whatsoever kind or nature and any cost, loss or expense in connection therewith arising from the Contest, including without limitation Sponsor’s use of the Design as contemplated therein.  




____________________________                        ______________________________

HOME PHONE                                               SIGNATURE OF WINNER

                                                                             ____________________________                            ______________________________

BUSINESS PHONE                                                PRINT FULL NAME OF 

                                                                        PARENT/LEGAL GUARDIAN

                                                         ____________________________                                                                              SIGNATURE OF PARENT/

                                                                         LEGAL GUARDIAN




Sworn to and subscribed before me this ______ day of _______________, 2020.



             NOTARY PUBLIC