Please complete the Guest Questionnaire below:

We are able to provide a Continental Breakfast for overnight guests and a light lunch for day stay visits and overnight guests. If you would like dinner in house as well, please indicate below. We ask for a small donation of $10 for evening meals.

Mary’s Place By The Sea is run by volunteers. Our services are provided free of charge by licensed practitioners. We will make every effort to accommodate your requests. Please notify us of cancellation within 24 hours of your reservation.

*If you are requesting an oncological massage, please check with your doctor to make sure it does not interfere with treatment.   

By submitting the form, you agree to the following disclaimer:

Mary’s Place By The Sea, Inc. is not a medical facility. We do not diagnose or treat disease.  We provide support and guidance and make nutritional recommendations only. We operate out of a single family home without an elevator. In the best interest of all guests and volunteers, we kindly reserve the right to deny accommodations to guests based on any number of considerations at the discretion of Mary’s Place by the Sea.  Mary’s Place By The Sea, Inc. is a therapeutic respite group home. My doctor is aware of my intent on this care and has not prescribed against it. By signing below I acknowledge that I understand this disclaimer and I will hold Mary’s Place By The Sea, Inc., its agents, employees, volunteers and directors, harmless against liability or claims that may arise out of my participation at this facility.

       

Salutation*
First Name*
Last Name*
Address Line 1*
Address Line 2
City*
State*
Zip Code*
Home Phone*
Cell Phone
Email Address*
How long is your visit?*
Check In Date* (Format: mm/dd/yyyy)
Check Out Date* (Format: mm/dd/yyyy)
Type of cancer*
Date of diagnosis* (Format: mm/dd/yyyy)
Age*
Where are you being treated?*
Emergency Contact Name*
Emergency Contact Phone*
Are you currently on pain medication?*

If Yes, please list medication(s)
Services*







Counselor*
Special Requests
How Did You Hear About Us?*
Prayer
Dietary Restrictions
Dinner In-House*
Digital Signature*
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