Print, and mail completed form to:
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):
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
For additional questions or comments, please call the WAVE coordinating Physician:
Caitlin Papastamelos, MD