EIRA Prospect

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 State
Birth Year *
Year in school *
Gender *
Rugby Club *
Height (feet, inches) *
Weight (lbs) *
Preferred Position *
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
Should be Empty: