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:

Assemblymember
Ellen C. Jaffee
One Blue Hill Plaza, Suite 1116
PO Box 1549
Pearl River, NY 10965
845-624-4601 jaffeee@assembly.state.ny.us