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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Favorite exercise done this summer

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

Assemblymember Kevin A. Cahill
Governor Clinton Building
1 Albany Avenue, Suite G-4
Kingston, New York 12401
(845) 338-9610
cahillk@assembly.state.ny.us

For ideas on what to read, check the Suggested Reading List.