Coach Powers Winter Break Coed Basketball Camp

DATE

December 29th-31st.

AGE

3rd-8th Graders

TIME

9AM-3PM

COST (includes T-shirt)

$195 per camper for 3 days, Sibling Discount $25 OFF

*Can't make all 3 days but want to come for some of camp? Email powersdc14@gmail.com

LOCATION:

LINTON HALL SCHOOL

9535 Linton Hall Rd

Bristow, VA 20136

Athlete Information

Parent/Guardian Information

Emergency Information

Informed Consent and Acknowledgement

I hereby give my approval for my child’s participation in any and all activities prepared by the Justin Powers Basketball Camp, during the selected camp. In exchange for the acceptance of said child’s candidacy by Justin Powers Basketball Camp, I assume all risk and hazards incidental to the conduct of the activities, and release, absolve and hold harmless Justin Powers Basketball LLC and all its respective officers, agents, and representatives from any and all liability for injuries to said child arising out of traveling to, participating in, or returning from selected camp sessions.

I realize that no environment is risk free, and so I have instructed my child on the importance of abiding by the camp’s rules, and my child and I both agree that he or she is familiar with these rules and will obey them.  I understand that if they do not follow camp rules they may be asked to leave camp with no refund.

I agree that venue for any dispute or cause of action arising between the parties, whether out of this agreement or otherwise, can only be brought in a court of competent jurisdiction located in Prince William County, Virginia, and such dispute or cause of action shall be governed by and construed in accordance with the laws of the Commonwealth of Virginia, exclusive of any provisions relating to conflict of laws.

I expressly agree that this release, waiver, and indemnity agreement is intended to be broad and inclusive as permitted by the law of the Commonwealth of Virginia, and that if any portion thereof is held invalid, it is agreed that the balance shall, notwithstanding, continue in full legal force and effect. This release contains the entire agreement between the parties hereto and the terms of this release are contractual and not a mere recital.

I further state that I HAVE CAREFULLY READ THE FOREGOING RELEASE AND KNOW THE CONTENTS THEREOF AND I SIGN THIS RELEASE AS MY OWN FREE ACT. This is a legally binding agreement, which I have read and have understood.

Medical Release and Authorization

As Parent and/or Guardian of the named athlete, I hereby authorize the diagnosis and treatment by a qualified and licensed medical professional, of the minor child, in the event of a medical emergency, which in the opinion of the attending medical professional, requires immediate attention to prevent further endangerment of the minor’s life, physical disfigurement, physical impairment, or other undue pain, suffering or discomfort, if delayed.

Permission is hereby granted to the attending physician to proceed with any medical or minor surgical treatment, x-ray examination and immunizations for the named athlete. In the event of an emergency arising out of serious illness, the need for major surgery, or significant accidental injury, I understand that every attempt will be made by the attending physician to contact me in the most expeditious way possible. This authorization is granted only after a reasonable effort has been made to reach me.

Permission is also granted to the Justin Powers Basketball LLC and its affiliates including Directors, Coaches, and Team Parents to provide the needed emergency treatment prior to the child’s admission to the medical facility.

This release is authorized and executed of my own free will, with the sole purpose of authorizing medical treatment under emergency circumstances, for the protection of life and limb of the named minor child, in my absence.

Confirmation

BY ACKNOWLEDGING AND SIGNING BELOW, I AM DELIVERING AN ELECTRONIC SIGNATURE THAT WILL HAVE THE SAME EFFECT AS AN ORIGINAL MANUAL PAPER SIGNATURE. THE ELECTRONIC SIGNATURE WILL BE EQUALLY AS BINDING AS AN ORIGINAL MANUAL PAPER SIGNATURE.