Effort Baptist Church Ministries
7820 Thomas Jefferson Parkway
Palmyra, VA 22963
434-589-8962
Effort Christian School and Preschool
www.EffortChristianSchoolandPreschool.com
434-808-2447
Effort After-School and Summer Day Program
For Office Use:
Date Rec’d: __________ Rec’d by _______
_____ Registration Fee(s)
_____ Immunization Form(s) or Waiver
_____ Birth Certificate(s) (copy made)
2013-2014 Registration
www.EffortChurch.org
434-808-2592
Child’s Full Legal Name: ______________________________________ Name Used: ________________
Date of Birth: ____________________________________ Age: _______ Gender: __________________
Please check the programs in which you are enrolling the above child: ___ Summer Day Program (school age)
___ Preschool (summer session) ____ Preschool (fall session) ____ School
_____ After-School (school age)
Child’s Full Legal Name: ______________________________________ Name Used: ________________
Date of Birth: ____________________________________ Age: _______ Gender: __________________
Please check the programs in which you are enrolling the above child: ___ Summer Day Program (school age)
___ Preschool (summer session) ____ Preschool (fall session) ____ School
_____ After-School (school age)
Child’s Full Legal Name: ______________________________________ Name Used: ________________
Date of Birth: ____________________________________ Age: _______ Gender: __________________
Please check the programs in which you are enrolling the above child: ___ Summer Day Program (school age)
___ Preschool (summer session) ____ Preschool (fall session) ____ School
_____ After-School (school age)
Complete Physical Address: __________________________________________________________________
Complete Mailing Address (if different) ________________________________________________________
Phone: ______________________________ Email: _____________________________________________
Phone number to receive recorded announcements, reminders, and information about inclement weather
closings and delays, etc.: __________________________________
*** If your child is new to our programs, please bring your child’s or children’s certified birth certificate
when you turn in your registration form, so we can photocopy it. We will not accept registration forms for
new children without a birth certificate. We require an official copy of your child’s up to date
immunization form or an immunization waiver form. ***
Child(ren) lives with: ______ Mother
______ Father ______ Other: _______________________________
Family Religious Preference: ____________________________ Church Attending: ______________________
2013-2014 Registration p. 2
Father’s Name:____________________________
Mother’s Name:____________________________
Preferred Name:___________________________
Preferred Name:___________________________
Employer Name & Address__________________
Employer Name & Address__________________
_________________________________________
_________________________________________
Daytime Phone ____________________________
Daytime Phone ____________________________
Cell Phone
Cell Phone
___________________________
Evening Phone ____________________________
___________________________
Evening Phone ____________________________
Emergency Contacts: (Contacts other than parents) In case of emergency, sudden illness, or circumstance requiring a
child to be picked up from one of our programs, the parents/guardians will be the first to be contacted. In the event we are
unable to reach a parent/guardian, we will contact one of the individuals you have authorized below to pick up your child.
.
Name:______________________________________ Relation:_____________________________________
Contact #s ______________________ _____________________________ __________________________
Name:______________________________________ Relation:_____________________________________
Contact #s ______________________ _____________________________ __________________________
Name:______________________________________ Relation:_____________________________________
Contact #s ______________________ _____________________________ __________________________
PICKUP INFORMATION (these are people
authorized to pick up your child in addition to your
emergency contacts listed above)
Name:_____________________________________
PHYSICIAN’S INFORMATION
Name:___________________________________
Relation:____________________________________
I grant personnel from Effort Baptist Church, Effort Christian School
& Preschool, After-School, or Summer Day Program permission to
obtain medical attention for my child(ren) in the case of emergency.
Name:_____________________________________
Relation:____________________________________
Name:_____________________________________
Relation:____________________________________
Phone Number:____________________________
____________________________________________ __________
Parent/Guardian Signature/
Date
_______________ ______________________________
Printed Name
List any information we may need to know about your child(ren) (medication, allergies, food restrictions, developmental
concerns, etc.) Our goal is to provide care to or educate all children, however, we are not staffed to accommodate
children with profound needs. We reserve the right not to accept children we are not qualified to serve. Please be specific
with child’s name and information.
Child’sName/Info:___________________________________________________________________________________
Child’sName/Info:___________________________________________________________________________________
Child’sName/Info:___________________________________________________________________________________
2013-2014 Financial Information

We use Smart Tuition for billing and receiving payments. Smart Tuition allows parents the
option of making payments by electronic check, debit card, credit card, phone, or by mail.
Parents are also able to check their account online 24/7. Once your child(ren)’s registration
form has been processed, you will receive a tuition agreement and login information for your
Smart Tuition account. Parents who pay for their tuition in full at the time of registration will not
need to login to Smart Tuition.

Fees for the Summer Day Program (school age children) and Summer Preschool are
made in 5 installments:
May 15
May 30
June 15
June 30
July 15
A late fee of $50.00 will be charged if payment is not received by the due date listed
above. If you use online banking or you are mailing a payment, be sure to allow 10 to 14
days for your payment to arrive to Smart Tuition. If you have special circumstance please
contact our church office 434-589-8962 or [email protected] to prior to the due date.
Any questions regarding Smart Tuition should be directed to our church office.

Fees for the School, Preschool, and After-School are billed in 9 monthly installments
(August through April.) This is a change for After-School which was previously billed in 10
monthly installments. The first month’s payment is due on August 1 and will satisfy the partial
attendance in May 2014. There will not be a payment in May. For families who enroll after
August, the May payment will be rolled into the regular monthly payments.

School, Fall Preschool Session, and After-School payments due on the 1st of the month.
A late fee of $50.00 will be charged if payment is not received by the due date. If you
use online banking or you are mailing a payment, be sure to allow 10 to 14 days for your
payment to arrive to Smart Tuition. If you have special circumstance please contact our
church office 434-589-8962 or [email protected] to prior to the due date. Any
questions regarding Smart Tuition should be directed to our church office. Past due accounts
of more than 30 days may result in suspension or dismissal from our programs. Smart Tuition
charges a $25.00 fee for returned checks.

Multi-child discounts vary per program or may not be offered for some programs. Please refer
to the program page of this registration form for more information about what is offered.
.
Effort Christian School 2012-2013
Junior Kindergarten – Fifth Grades; 6th -8th Grades Depending on Enrollment
Name of Student: _______________________________Grade: ________
Name of Student: _______________________________Grade: ________
Name of Student: _______________________________Grade: ________
School Hours 8:30 a.m. – 3:00 p.m.
Tuition: $430.00/month
Non-Refundable* Enrollment and Book Fee: $145.00
* This fee will be refunded if the class is full or if the 6th-8th grades are not offered
Other Programs Available:
______ Early Drop Off (7:00-8:30 a.m.)
Mon-Fri
$ 70.00/month
______ After-School (3:00 – 6:00 p.m.)
1-3 days/week
$ 75.55/month **
______ After-School (3:00 – 6:00 p.m.)
4-5 days/week
$124.45/month**
______ Preschool After-School (3:00-6:00 p.m.)(Jr. K)1-3 days/wk $ 94.44/month
______ Preschool After-School (3:00-6:00 p.m.)(Jr. K)4-5 days/wk $150.00/month
After-School Registration Fee (non-refundable) $25.00
** Effort Christian School students (Kindergarten and up) enrolled in the After-School program receive
a 20% discount off of regular After-School fee. Junior Kindergarten students attend Preschool AfterSchool.
We offer a discount to families who have more than one child enrolled. The discount does not apply
to Early Drop-Off, After-School, or Preschool After-School.


First school child (or highest tuition) is full tuition; second and additional school children are
tuition discounted 30%.
For families with children in both our school and preschool programs, the child enrolled in
school is full tuition, and the first preschool child is tuition discounted 10%; the third and
additional preschool children are discounted 15%
Tuition assistance is available on a case by case basis. Applications for tuition assistance are
available in the Effort Baptist Church office, at the information centers in the Sanctuary and Family
Life Center foyers.
For more information, please visit our website www.EffortChristianSchoolandPreschool.com or
contact Joyce Parr 434-808-2447 or [email protected] .
Effort Christian Preschool 2013-2014 SUMMER SESSION May 21-Aug. 7
Preschool SUMMER Registration Fee (non-refundable)
$40.00
Preschool SUMMER After-School Registration Fee (non-refundable) $25.00
Note: Three year old and Pre-K children must be the age of the class by September 30 to be enrolled in
the class.
Preschool Summer Session will be billed in 5 installments instead of monthly. This is a change from the
way it was done last year. The due dates are listed below and the amounts due are listed next to the
corresponding classes.
May 15
May 30
June 15
June 30
July 15
Circle the class in which each child(ren) will be enrolled:
Child’s Name: ___________________________ rising 2
rising 3
rising Pre-K
rising K
Child’s Name: ___________________________ rising 2
rising 3
rising Pre-K
rising K
Child’s Name: ___________________________ rising 2
rising 3
rising Pre-K
rising K
Check your child(ren)’s schedule below: (Our two day schedules are Tues/Thurs and three day
schedules are Mon/Weds/Fri. If you would like a different schedule, we may be able to accommodate
depending on space. You may write it to the right of the your child’s schedule.)
____Rising 2 year old – Early Drop-Off 7:00-9:00--------------- $ 38.50
____Rising 2 year old – 2 days 9:00-12:00 ----------------------- $ 96.25
____Rising 2 year old - 3 days 9:00-12:00 ------------------------ $115.50
____Rising 2 year old - 5 days 9:00-12:00 ------------------------ $143.00
____Rising 2 year old – 2 days 9:00-3:00 ------------------------- $143.00
____Rising 2 year old – 3 days 9:00-3:00 ------------------------- $198.00
____Rising 2 year old – 5 days 9:00-3:00 ------------------------- $266.80
____Rising 2 year old – Preschool After-School 2-3 days 3:00-6:00 p.m.-$ 51.94
____Rising 2 year old – Preschool After-School 4-5 days 3:00-6:00 p.m.-$ 82.50
____Rising 3 year old, rising Pre-K, rising K - Early Drop-Off 7:00-9:00. -----------------------------$ 38.50
____Rising 3 year old, rising Pre-K, rising K - 2 days 9:00-12:00 ---------------------------------------$ 90.75
____Rising 3 year old, rising Pre-K, rising K - 3 days 9:00-12:00 ---------------------------------------$115.50
____Rising 3 year old, rising Pre-K, rising K - 5 days 9:00-12:00----------------------------------------$137.50
____Rising 3 year old, rising Pre-K, rising K - 2 days 9:00-3:00 -----------------------------------------$137.50
____Rising 3 year old, rising Pre-K, rising K - 3 days 9:00-3:00------------------------------------------$192.50
____Rising 3 year old, rising Pre-K, rising K - 5 days 9:00-3:00 -----------------------------------------$261.25
____Rising 3 year old, rising Pre-K, rising K - Preschool After-School 2-3 days 3:00-6:00 p.m.-$ 51.94
____Rising 3 year old, rising Pre-K, rising K - Preschool After-School 4-5 days 3:00-6:00 p.m.-$ 82.50



Tuition assistance is available on a case by case basis. Applications for tuition assistance are available
in the Effort Baptist Church office or on our website www.EffortChristianSchoolandPreschool.com.
We offer a discount to families who have more than one child enrolled in Effort Christian School and
Preschool programs. The discount does not apply to Early Drop-Off, After-School, or Preschool AfterSchool. The discounts are as follows:
- First preschool child (or highest tuition) is full tuition; second preschool child (or next highest
tuition) is tuition discounted 10%; third child and additional preschool children are tuition
discounted 15%.
For more information, please visit our website www.EffortChristianSchoolandPreschool.com or contact
Joyce Parr 434-808-2447 or [email protected]
Effort Christian Preschool 2013-2014 FALL SESSION starts August 14
Preschool FALL Registration Fee (non-refundable) per child enrolled: $55.00
Preschool Fall After-School Registration Fee (non-refundable) per child enrolled: $25.00
Note: Three year old and Pre-K children must be the age of the class by September 30 to be
enrolled in the class.
Please check your preference:
Monthly Tuition
______ 2 year old – Early Drop-Off 7:00-9:00 a.m. -- $70.00
child’s name: __________________________
______ 2 year old – 2 days 9:00-12:00 ---------------- $175.00
______ 2 year old – 3 days 9:00-12:00 ---------------- $210.00
______ 2 year old – 5 days 9:00-12:00 ---------------- $260.00
______ 2 year old – 2 days 9:00-3:00 ------------------ $260.00
______ 2 year old – 3 days 9:00-3:00 ------------------ $360.00
______ 2 year old – 5 days 9:00-3:00 ------------------ $485.00
______ 2 year old – Preschool After-School 2-3 days 3:00-6:00 p.m. 94.44*
______ 2 year old – Preschool After-School 4-5 days 3:00-6:00 p.m. 150.00*
______ 3 year old - Early Drop-Off 7:00-9:00 a.m. --- $70.00
______ 3 year old – 2 days 9:00-12:00 ---------------- $165.00
______ 3 year old – 3 days 9:00-12:00 ---------------- $210.00 child’s name: ___________________________
______ 3 year old – 5 days 9:00-12:00 ---------------- $250.00
______ 3 year old – 2 days 9:00-3:00 ------------------ $250.00
______ 3 year old – 3 days 9:00-3:00 ------------------ $350.00
______ 3 year old – 5 days 9:00-3:00 ------------------ $475.00
______ 3 year old – Preschool After-School 2-3 days 3:00-6:00 p.m. 94.44*
______ 3 year old – Preschool After-School 4-5 days 3:00-6:00 p.m. 150.00*
______ Pre-K – Early Drop-Off 7:00-9:00 a.m. -------- $70.00
______ Pre-K – 2 days 9:00-12:00 ---------------------- $165.00
______ Pre-K – 3 days 9:00-12:00 ---------------------- $210.00
______ Pre-K – 5 days 9:00-12:00 ---------------------- $250.00 child’s name: __________________________
______ Pre-K – 2 days 9:00-3:00 ------------------------ $250.00
______ Pre-K – 3 days 9:00-3:00 ------------------------ $350.00
______ Pre-K – 5 days 9:00-3:00 ------------------------ $475.00
______ Pre-K – Preschool After-School 2-3 days 3:00-6:00 p.m. 94.44*
______ Pre-K – Preschool After-School 4-5 days 3:00-6:00 p.m. 150.00*
 Tuition assistance is available on a case by case basis. Applications for tuition assistance are
available in the Effort Baptist Church office or on our website
www.EffortChristianSchoolandPreschool.com.
 For more information, please visit our website www.EffortChristianSchoolandPreschool.com or
contact Joyce Parr 434-808-2447 or [email protected]
 We offer a discount to families who have more than one child enrolled in Effort Christian
School and Preschool programs. The discount does not apply to Early Drop-Off, After-School,
or Preschool After-School. The discounts are as follows
o First preschool child (or highest tuition) is full tuition; second preschool child (or next
highest tuition) is tuition discounted 10%; third child and additional preschool children
are tuition discounted 15%
2013 Effort Summer Day Program (completed K – 5th grades) May 28-Aug. 2
Summer Day Program Registration Fee (non-refundable) per child enrolled: $45.00
Child’s Name: __________________________________ Grade Entering: _________
Child’s Name: __________________________________ Grade Entering: _________
Child’s Name: __________________________________ Grade Entering: _________
There are three Summer Day Program options: (Please select one.)
_____ 8 week option (full time - $1,360.00 or part time - $1,040.00)
_____ 9 week option (full time - $1,530.00 or part time - $1,170.00)
_____10 week option (full time - $1,700.00 or part time - $1,300.00)
Please select the weeks and days your child(ren) will be attending: If you need to make
changes, please notify Jiffy Holland 1 week prior to the change.
Week #
week 1
week 2
week 3
week 4
week 5
week 6
week 7
week 8
week 9
week 10
Week
Beginning
5/27/13
6/3/13
6/10/13
6/17/13
6/24/13
7/1/13
7/8/13
7/15/13
7/22/13
7/29/13
Week
Ending
5/31/13
6/7/13
6/14/13
6/21/13
6/28/13
7/5/13
7/12/13
7/19/13
7/26/13
8/2/13
Will
Attend
Days Attending
T W T
M T W T
M T W T
M T W T
M T W T
M T W
M T W T
M T W T
M T W T
M T W T
F
F
F
F
F
F
F
F
F
F
all
all
all
all
all
all
all
all
all
all
Summer Day Program payments may be paid in full or in 5 installments which are listed below:
May 15

May 30
June 15
June 30
July 15
Parents have the option of prepaying the Summer Day Program cost for a 5% discount or
making payments in the five installments listed above.

The full- time rate (4-5 days a week) is $170.00 and the part-time (1-3 days a week) is $130.00
per week. We will calculate the total number of weeks attending for your total Summer Day
Program cost. If you select to make installment payments, then we will divide the total number
by 5 for each installment. Once your child(ren)’s registration form has been processed, you
will receive a tuition agreement.

For more information, you may visit our website www.effortchurch.org or contact Jiffy Holland
434-808-2592 or [email protected]
2013-2014 Effort After-School (school age K-5th)
Starts the first day of school for Fluvanna County Public Schools
After-School Registration Fee (non-refundable) per child enrolled: $25.00
Child’s Name: ___________________________________ Grade Entering: __________
Child’s Name: ___________________________________ Grade Entering: __________
Child’s Name: ___________________________________ Grade Entering: __________
Information:





Fluvanna County Public Schools will provide transportation to the Effort After-School Program.
The Effort After-School Program will be closed on days the Fluvanna County Public Schools
are closed and for early dismissal days.
Pick-up is no later than 6:00 p.m. Extra fees will apply for late pick-ups.
When updating your school transportation information, please be sure to note your child will be
participating in the Effort After-School Program.
Note Change: The After-School cost is the same as the previous year, however we are
now billing in 9 monthly installments (August - April) instead of 10 monthly installments
to be consistent with the other programs.
Please check one of the following schedules:
______ Full-time enrollment (4-5 days per week)

1 child
$155.56 per month

2 children
$285.55 per month ($142.78 per child)

3 children
$410.00 per month ($136.67 per child)
______ Part-time enrollment (1-3 days per week)

1 child
$ 94.44 per month

2 children
$174.44 per month ($87.22 per child)

3 children
$250.00 per month ($83.33 per child)
______ Part-time enrollment (1-3 days per week) Please specify days: _______________________
For more information about After-School, you may visit our website www.effortchurch.org or contact
the Jiffy Holland 434-808-2592 or [email protected] .