Information form

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Child’s name:

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Parent/Guardian name:

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Address1:

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Address2:

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Phone/E-mail:

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Number of days completed::

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Favorite book read this summer:

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Number of years participated in the Summer Reading Challenge:

To receive your certificate, please complete the above form and send it with the calendar to:

Assemblyman
Felix W. Ortiz
404 55th Street • Brooklyn, NY 11220
718-492-6334
Room 826, LOB • Albany, NY 12248
518-455-3821
ortizf@assembly.state.ny.us