Excellence in Reading and Fitness Certificate
Information Form


Child’s Name (First, Last)

School

Grade as of 6/08

Parent or Guardian Name (First, Last)

Address 1

Address 2

Phone/E-mail

Number of Days Completed.

Total Number of Points

To receive your certificate and be eligible for a medal, please have your parents complete the above form and send it with the attached calendar to:

Assemblyman Michael J. Cusick
1911 Richmond Avenue
Staten Island, NY 10314
(718) 370-1384
cusickm@assembly.state.ny.us


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