How to Apply

Application and Required Forms
Prior to your initial evaluation, your application and physician’s clearance must be sent to Push to Walk either by fax (201-644-7568) or email kwolfe@pushtowalknj.org

Potential clients please review and complete one of the forms below.

Spinal Cord Injury Application (PDF Format)
Spinal Cord Injury Application (Word Document Format)
Multiple Sclerosis Application (PDF Format)
Multiple Sclerosis Application (Word Document Format)
Brain Injury/Cerebral Palsy/Stroke/Other Application (PDF Format)
Brain Injury/Cerebral Palsy/Stroke/Other Application (Word Document Format)

**All clients must be independent of a ventilator.**

Client Responsibilities
Clients must be able to maintain their appointments on a consistent basis, have reliable transportation and the financial ability to pay the hourly fee of $105. Scholarship funds are available to individuals who qualify.

Still not sure if you’re a candidate?

Please complete the form below, and a Push to Walk team member will get back to you.

APPLY NOW

First name *

Last name *

Phone *

Email adress *

Address *

City *

State & ZIP Code *

Age *

Injury level / diagnosis *

Date of injury *

Height & Weight *

Current health condition *

Secondary health complications *

Please explain any other health condition *

How did you hear about us? *