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, ____________________________ (Parent/ Guardian),

have received and reviewed the Information packet regarding

the NJ Wave Program, sponsored by the American Lung

Association. I do, hereby, give my permission/release

for ___________________ (Child) to attend this residential

program from June 27  through June 30, 2011, and to

participate in all associated activities.