Schedule Your Stay with Us

Schedule a stay at Mary’s Place begins with completing the following Guest Questionnaire.  Please complete all information to ensure proper scheduling.  Once the Guest Questionnaire is submitted (by pressing the Submit button at the end of the page), it is sent via email to our office.  You will be contacted within 72 hours.  Every effort will be made to accommodate your requests.

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 doctor indicating you are under their care is needed. If you are requesting an oncology massage, please check with your doctor to make sure it does not interfere with your treatment. A doctor's note stating you are cleared to receive an oncology massage is needed prior to arrival.   Please notify us of cancellation within 48 hours of your date of arrival.

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*
Zip Code*
Home Phone*
Cell Phone
Email Address*
How long would you like visit?*
Requested Check In Date*
Requested Check Out Date*

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*
Age*
Birthday*
Where are you being treated?*
Emergency Contact Name*
Emergency Contact Phone*
Are you currently on pain medication?*

If Yes, please list medication(s)

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*

Please select 3 services you would like while you are here at Mary's Place. We will make every effort to accommodate your requests based on the availability of our practitioners.

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 a dietary restriction or food allergy?*
If YES, please specify your Dietary Restrictions or Food Allergy

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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