Print and mail completed form to:

      New Jersey WAVE

      c/o Voorhees Pediatric Facility

      Attention: Tricia Cunningham

      1304 Laurel Oak Road

      Voorhees, NJ 08034-4392 


      I agree to allow the Wave staff to review the personal and

      medical information contained in this packet.  I also agree

      to have this information reviewed by the physicians

      providing medical clearance for WAVE getaway



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         Applicant)                                                              (Date)                                                                                  


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      (Parent)                                                                  (Date)