EIRA Prospects Survey
Please complete if you are interested in an opportunity
Player Name
*
First Name
Last Name
Parent Name
*
First Name
Last Name
Parent email
*
Confirmation Email
example@example.com
Player email
*
Confirmation Email
example@example.com
Parent cell #
*
-
Area Code
Phone Number
City and State
*
Street Address
Street Address Line 2
City
Please Select
Alabama
Alaska
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District of Columbia
Florida
Georgia
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Ohio
Oklahoma
Oregon
Pennsylvania
Puerto Rico
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
Vermont
Virgin Islands
Virginia
Washington
West Virginia
Wisconsin
Wyoming
State
Zip Code
Birth Year
*
2004
2005
2006
2007
2008
2009
2010
Year in school
*
6th
7th
8th
9th
10th
11th
12th
Post high school
Gender
*
Male
Female
Rugby Club
*
Height (feet, inches)
*
5.0
5.1
5.2
5.3
5.4
5.5
5.6
5.7
5.8
5.9
5.10
5.11
6.0
6.1
6.2
6.3
6.4
6.5
6.6
6.7
6.8
6.9
6.10
Weight (lbs)
*
Preferred Position
*
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
Why do you want to be a part of EIRA?
*
Describe the best aspects of your game
*
What parts of your game need to get better?
*
Coach 1 Reference
*
First Name
Last Name
Coach 1 Email
*
Confirmation Email
example@example.com
Coach 2 reference
First Name
Last Name
Coach 2 Email
Confirmation Email
example@example.com
Submit
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