Schedule Your Stay with Us

Please note that we recommend completing this questionnaire on a computer, rather than a cell phone. Scheduling a stay at Mary’s Place begins with completing the following Guest Questionnaire.  Please complete all information required, and press the submit button at the bottom of the page.  You will be contacted within 72 hours; in the event that you are not contacted within 72 hours, please contact our office to confirm that we have received your questionnaire. Every effort will be made to accommodate your requests. Mary's Place by the Sea welcomes WOMEN diagnosed with any type of cancer, who are in active treatment or up to one year post-treatment.  
**Please note that we are currently booked through December 31, 2019. If you are interested in being on a WAIT LIST, please select dates when you would like to be on the wait list. (UPDATED 8/9/19)
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*Please also note that we will be accepting applications for January, February and March of 2020 beginning on October 1st, 2019. (UPDATED 8/9/19)

Overnight Visits

  1. Overnight Guests may check-in on Tuesdays or Fridays for a two-night stay. 
  2. Overnight Guests may check-in on Tuesday, Wednesday, Friday or Saturday for a one-night stay.
  3. Check-in time is 10:30 AM. Check-out time is 11:00 AM. 
     

Day Visits

  1. Day Guests may visit Tuesday-Saturday. 
  2. Check-in time may vary.
     

Mary’s Place By The Sea is operated by volunteers. Our services are provided free of charge by licensed practitioners. Please note: A letter from your oncologist stating that you are under their care is required. If you are requesting an oncology massage or reflexology, please check with your doctor to make sure it does not interfere with your treatment. Your oncologist should also indicate that you are are cleared to receive an oncology massage and/or reflexology, should you wish to receive those services. A letter of clearance may be from your Doctor's office prior to your arrival, or you may bring it with you. 

Are you a New or Returning Guest?*

Salutation*
First Name*
Last Name*
Address Line 1*
Address Line 2
City*
Select Your County*
If outside of New Jersey (Other), what County?
State*
Country*
If outside of USA, please list country:
Zip Code*
Home Phone*
Cell Phone
Email Address*
How long would you like to visit?*

**Please note that we are currently booking overnight guest visits six months in advance.

Requested Check In Date*
Requested Check Out Date*
How will you be arriving to and departing from Mary's Place?*

Check-in and Check-out is at 11am.

Please note: You will be personally contacted within 72 hours to confirm your reservation.  If you have not received a call, please contact us at 732-455-5344.

Type of cancer*
Date of diagnosis (Date Format must be MM/DD/YYYY)*
Are you currently in treatment?*
 
If no, date of last treatment:
Where are you being treated?*
Age*
Birthday (Date Format must be MM/DD/YYYY)*
Emergency Contact Name (Person to be on-call during your visit in case of an emergency)*
Emergency Contact Phone (This number must be DIFFERENT from your phone number)*
Emergency Contact Email Address*
Emergency Contact Relation*
Are you currently on pain medication?*

If Yes, please list medication(s)
Please list the dosage and frequency of any medications.

Please indicate "Additional Medical Information" below: If you have any other medical or health condition we should be made aware of in an effort to protect all of our guests, volunteers and staff members. If none, simply state "none". This information will be kept confidential.

Additional Medical Information*
To help us ensure your safety, please let us know what type of medical assistance you require on a daily basis. (Check all that apply.)*




Please select 2-3 of the following INDIVIDUAL services that you MAY BE interested in receiving during your stay. (We do our best to accommodate your desired services based on the availability of our practitioners). Please note that we require a note from your oncologist, stating that you are under their care. Your oncologist must also indicate that you are cleared to receive oncology massage and/or reflexology if you wish to receive those services.

Individual Services*




PLEASE SELECT THE FOLLOWING GROUP SERVICES THAT YOU MAY BE INTERESTED IN RECEIVING DURING YOUR STAY. (WE DO OUR BEST TO ACCOMMODATE YOUR DESIRED SERVICES BASED ON THE AVAILABILITY OF OUR PRACTITIONERS).

Group Services*




You only need to indicate your Prayer Tradition if you are requesting prayer. Thank you.

Prayer Tradition (please indicate)
Would you like to receive individual counseling during your stay?*
Special Requests
How Did You Hear About Us*
Do you have any dietary restrictions or food allergies?*
Please list any dietary restrictions or food allergies.

 

TERMS AND CONDITIONS

1. I understand that Mary’s Place by the Sea is a non-smoking facility.*

2. I understand that Mary’s Place has zero tolerance for firearms, illegal drugs and alcohol.*

3. To maintain the peace and tranquility of the home, I agree to return to the house by 10PM.*


4. I agree not to share any medication with anyone at Mary’s Place by the Sea.*

5. I understand that Mary’s Place by the Sea is not responsible for lost or stolen items.*

6. I understand that I need to present a note from my oncologist in order to visit Mary's Place.*

7. I understand that my oncologist must indicate that I am cleared for oncology massage and reflexology, should I wish to receive either of those services.*

8. I understand that all services are COMPLIMENTARY, and that every effort will be made to provide my desired services based on the availability of practitioners.*

9. I understand that Mary's Place by the Sea reserves the right to call 911 in the event of an emergency and at the discretion of the staff and volunteers.*

Photo and Video Disclaimer: From time to time, we capture photos and/or videos of our guests and visitors to be used on social media sites including our social media pages and other printed materials such as our brochure. We respect your privacy and request your permission to take an occasional photo of you during your stay at Mary's Place by the Sea. Please indicate your permission by selecting "yes" or "no".

Photographs and Videos*
Digital Signature*
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