New York State Assembly
Excellence in Reading Certificate
Information Form

Child’s name  arrow

School  arrow

Parent/Guardian name  arrow

Address 1  arrow

Address 2  arrow

Phone  arrow
E-mail  arrow

Number of days completed  arrow

Favorite book read this summer  arrow

Number of years participated in the Summer Reading Challenge  arrow

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

Assemblyman N. Nick Perry

903 Utica Avenue
Brooklyn, NY 11203