| New York State Assembly Excellence in Reading Certificate Information Form | 
| Child’s Name | 
| School | 
| Parent or Guardian Name | 
| Address | 
| Phone/E-mail | 
| Number of Days Completed | 
| Favorite Books | 
| To receive your certificate, please have your parents complete the above form and send it with the attached calendar to: 
		
		Assemblymember  | 
| Back |