• Eastern Shore Coed Basketball Camp

    Registration Form
  • DATES

    MONDAY THROUGH WEDNESDAY

    JUNE 15TH-17TH 2026

    GRADES

    Rising 3rd-9th Graders

    TIME

    8:30AM-12:30PM

    COST (Includes a T-shirt)

    $130, *10% OFF SIBLING DISCOUNT

    REGISTER BEFORE JUNE 1ST TO GUARANTEE YOUR CHILD GETS A T-SHIRT

    * PAY OVER TIME WITH A DEPOSIT OPTION OR PAY LATER OPTION

    LOCATION:

    NORTHAMPTON COUNTY PARKS AND RECREACTION CENTER

    7247 YOUNG STREET
    MACHIPONGO, VA 23405

    *Bring Your Own Basketball, we will have extras if you forget

     

    QUESTIONS??? Email: justin@powersbballcamp.com

  • Athlete Information

  • What Grade will your child be in during 2026-2027 school year? (Next year)*
  • T-Shirt Size*
  • Do you want to register a sibling? (skip if not applicable)

    Go to Parent Information if you are registering for one child.
  • What Grade will your child be in during 2026-2027 school year? (Next year)
  • T-Shirt Size
  • Parent/Guardian Information

  • Format: (000) 000-0000.
  • Informed Consent and Acknowledgement

    I hereby give my approval for my child’s participation in any and all activities prepared by the Coach Powers Basketball Camp, during the selected camp. In exchange for the acceptance of said child’s candidacy by Coach 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.

  • 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.

  • Payment Options*

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            Camper Payment

            Includes a T-shirt

            $130.00$130.00
              
            Two Campers Payment

            10% off discount for siblings. Includes a T-shirt.

            $234.00$234.00
              
            Camper Deposit

            Includes a T-shirt

            $75.00$75.00
              
            Two Campers Deposit

            Includes a T-shirt

            $134.00$134.00
              
            Subtotal
            $0.00$0.00
            Tax
            $0.00$0.00
            Total
            $0.00$0.00
          • Payment Methods

            Choose from one of the PayPal options to make your payment.

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