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
Jeffrey Dinowitz
3107 Kingsbridge Avenue
Bronx, NY 10463
718-796-5345
dinowitzj@assembly.state.ny.us