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This form is only for players of Rugby Indiana who are requesting financial assistance to play in our seasons. This form is not for scholarships in other areas (outside of Indiana) or age groups (college / adult).

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Player Name(Required)

First Name Last Name

Player Full Address(Required)

Street Address Address Line 2 City State ZIP Code

Player Phone #(Required)

Player/Parent Email Address(Required)

Player’s Club Team Name

Player Grade

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