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

Dear Doctor,


Your patient, _______________________, has applied to participate in WAVE, the NJ shore getaway for children 

 who have tracheostomies, who are ventilator-dependent, or have specialized medical needs.  Please refer to the informational brochure for details. 


Please review your patient's application information

 (enclosed) for accuracy and completeness.



Patient's Diagnosis (medical issues):










Allergies: ________________________________________________________


Motion Sickness: _________________________________________________



Recent Medical Problems:





 Your patient should be medically stable to participate in WAVE. 

Of note, your patient may not be attending with his/her usual

home caretakers, in order to foster independence and maturation.  Participants will be cared for at the getaway by experienced professionals.


Do you believe that _________________________________

is medically stable to participate in



ÿ  YES  ÿ NO      







To the best of my knowledge, the above information

 is correct


Date   ______________                   


Name __________________________________      

Title __________________



Address ________________________________________








For additional questions or comments, please call the WAVE coordinating Physician:

Caitlin Papastamelos, MD

Pediatric Pulmonology