This is the printed version of the Camp Floyd Rogers registration form. The preferred method is to
register online. If possible, please visit www.campfloydrogers.com and register online. The online
registration will allow for all payment options, including credit card, checks/money order, requesting a
campership and sponsorship. Additionally, it is the quickest way to be accepted.
Camper Registration
Camper’s Full Name: ________________________________________________________________________
Date of Birth: _______________
Camper must be 8-17 years old.
School Grade Recently Completed:_____________
Gender: MALE / FEMALE
Circle the appropriate answer.
First Time At Camp: YES / NO
Circle the appropriate answer.
Special Dietary Needs (Not Dislikes): YES / NO
Circle the appropriate answer and provide a description below if “YES”.
Special Needs (Not Dietary or Diabetes): YES / NO
Circle the appropriate answer and provide a description below if “YES”.
Parent/Guardian Information
Parent/Guardian Name: ___________________________________________________________
Parent/Guardian Address: _________________________________________________________
City: ______________________ State: ______________ Zip Code: _______________________
Parent/Guardian Email: ___________________________________________________________________
This email will be used for all Camp Floyd Rogers communication.
Parent/Guardian Alternate Email: ___________________________________________________________
This alternate email will be used for all Camp Floyd Rogers communication.
Parent/Guardian Primary Phone Number: _____________________________________________________
This will be listed as the primary emergency phone number.
Parent/Guardian Secondary Phone Number: ___________________________________________________
This will be listed as the secondary emergency phone number.
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Cancellation Policy
If a camper is unable to attend camp, please let us know at the earliest convenience. Cancellations prior to May
15th will receive a full refund minus a $50 administrative processing fee. Cancellations after May 15th will not
be eligible for a refund. If a camper is accepted with a campership or scholarship and fails to cancel by May 15th
or is a no show to camp, the camper will not be able to apply for a campership or sponsorship the following year
and may result in a permanent ineligibility of financial assistance.
I have read and understand the cancellation policy: YES / NO
Circle the appropriate answer.
Payment Methods
The paper form will only allow registration with check and campership. If additional payment options are
needed, please visit www.campfloydrogers.com and register online.
The camper's spot will not be guaranteed until full payment is received or campership is awarded.
Camp Floyd Rogers Merchandise
PLEASE NOTE! Merchandise will be available for purchase during camper registration only and will be
available at check in. Campership requests will require the payment of any merchandise ordered.
Camp Floyd Rogers T-shirt - $15 each
The T-shirt color and design changes each year and will include the Camp Floyd Rogers logo. Hanes 50% cotton
and 50% polyester T-shirt fits well on both sexes.
Youth: (XS) (S) (M) (L) (XL)
Adult: (S) (M) (L) (XL) (2XL) (3XL)
Circle the size(s) above and indicate desired quantity of each: ______________
Camp Floyd Rogers Sweatshirt - $30 each
The sweatshirt color and design changes each year and will include the Camp Floyd Rogers logo. Hanes 100%
cotton sweatshirt fits well on both sexes.
Youth: (XS) (S) (M) (L) (XL)
Adult: (S) (M) (L) (XL) (2XL) (3XL)
Circle the size(s) above and indicate desired quantity of each: ______________
Camp Floyd Rogers Sweatpants - $30 each
The sweatshirt color and design changes each year and will include the Camp Floyd Rogers logo. Hanes 100%
cotton sweatshirt fits well on both sexes.
Youth: (S) (M) (L) (XL)
Adult: (S) (M) (L) (XL) (2XL) (3XL)
Circle the size(s) above and indicate desired quantity of each: ______________
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Camp Floyd Rogers Water bottle - $10 each
Quantity: ___________
Pay With Check
Camp Fee Paid By Check: $550
Merchandise Total From Above: $_________
Total To Be Paid By Check: $_________
To pay by check, please make payable to Camp Floyd Rogers with the campers name in the memo:
Request Campership
In an effort to make sure that no child is turned away from Camp Floyd Rogers for financial reasons, we have
established a limited number of Camperships. If you are interested in applying for one of these Camperships,
please complete the section below. To ensure the Camperships go as far possible, please request only the amount
that is needed (e.g. requesting $200 but able to pay $300). Please include a check with the registration from for
the amount able to pay including any merchandise. Make checks payable to Camp Floyd Rogers with the
campers name in the memo. Campership requests begin to be evaluated and awarded in April of each year.
Campership Amount Requested: $_________
The Campership amount being requested must be entered and cannot exceed the entire camp fee of $550.
Merchandise Total From Above: $_________
Campership requests will require payment of any merchandise ordered and is not included with the campership.
Remaining To Be Paid By Check: $_________
This is the amount of the camper fee and any purchased merchandise you will be responsible for.
Checks or money orders must be payable to Camp Floyd Rogers with the camper's name in the memo.
Is the camper on the National School Lunch Program: YES / NO
Circle the appropriate answer.
Please provide an explanation as to why the camper should be considered for a campership.
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Once completed, please mail to:
Camp Floyd Rogers
PO BOX 541058
Omaha, NE 68154
I, the parent or guardian of the above named participant, agree that if the child is accepted to Camp Floyd Rogers
that their diabetes will be kept under the medical supervision of the camp licensed medical providers during the
duration of camp. I voluntarily assume the risk associated with a child with Type 1 Diabetes attending an
outdoor camp that has activities including but not limited to trust courses, zip lining, archery, riflery, and sports
activities. I hereby release, exonerate, and discharge Camp Floyd Rogers, the Floyd Rogers Diabetic Foundation,
any individual involved with the camp or the board from any and all liability, demands, actions, and causes of
actions whatsoever as well as the acts and actions of its heirs, successors, employees, agents, independent agents,
contractors for acts of passive or active negligence or any other intentional or unintentional acts resulting in any
loss, damage, or injury, including death, that may be sustained by the camper or to property belonging to the
camper while participating in Camp Floyd Rogers. It is understood that in case of accident, injury or illness
requiring hospital admission, I authorize the Camp Director or member of the camp medical staff to act for me in
my absence. I acknowledge and accept that any expense thereof will be the responsibility of the parents or
guardians. I grant permission to the camp and its agents to photograph the child and to use, publish or release for
publication the child’s first name and such photographs or digital media on the camp's webpage and/or the
camp's social media sites. These photos or digital media may be released to publications for camp promotion and
will conform to standards of good taste. If this is not understood and accepted, this form must not be submitted.
Signature: _____________________________________________
Date: ______ / ______ / __________
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