Print and mail completed form to:

      New Jersey WAVE

      c/o Voorhees Pediatric Facility

      Attention: Tricia Cunningham

      1304 Laurel Oak Road


      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



      _____________________________                 _________

         Applicant)                                                              (Date)                                                                                  


      ____________________________                 ___________                                                                          

      (Parent)                                                                  (Date)