Practitioner Application Form
“Give your hands to serve, and your hearts to love.” - Mother Teresa

Thank you for your interest in becoming a Practitioner at Mary's Place by the Sea. We are blessed to have over 50 active practitioners giving their time, talents and love to our mission!

Please fill out the form below and click "Submit" to send your application in to us. A copy of your responses will be emailed to you and someone from our team will be in touch soon.

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Email *
First Name *
Last Name *
Street Address *
City *
State *
Zip Code *
Primary Phone *
Is Primary Phone *
Date of Birth *
MM
/
DD
/
YYYY
Emergency Contact - Full Name *
Emergency Contact - Phone Number *
How did you hear about us? *
Please indicate the dates and times you are usually available to provide services. *
Morning
Afternoon
Evening
Not Available
Monday
Tuesday
Wednesday
Thursday
Friday
Saturday
Please indicate any months you are NOT available.   *
Required
Please indicate the type of service(s) you would like to offer at Mary's Place by the Sea. Check all that apply. *
Required
If you selected "Other," please provide the name of your service along with a short description.
Are you licensed and/or certified in your particular field? If yes, you may be asked to provide a copy of your license/certification. *
Required
Do you have liability insurance for your particular service? If yes, you may be asked to provide a copy of your insurance policy. *
Are you actively practicing in your field? *
If yes, please provide information on where you are currently practicing. 
Why do you wish to offer your services as a Practitioner at Mary's Place by the Sea? *
Please share any additional information you would like us to know about you.
A copy of your responses will be emailed to the address you provided.
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