First Name * :
Last Name * :
Address * :
Suburb * :
State * :
Postcode * :
Mobile * :
Email * :
Sport or recreation type * :
Team Name (where applicable) :
Organisation (where applicable) :
Is the nominee aware of this nomination? *:
I am self nominating.
Relationship to nominee (ie. Family member, colleague, coach, organisation) * :
How did you find out about the awards?
---DSR websiteDSRF websiteDSR Vortex NewsletterDSR emailState Sporting AssociationDisability sports organisationCommunity organisationLocal clubCouncilOther (please specify)
Please specify the other
1. In the past twelve months, the nominee has coached:Please select all that are applicable.
Local competition Regional competition State competition National competition International competition
2. The following relate to the nominee’s impact. The nominee has:Please select all that are applicable.
Made a significant impact to a club, local community, organisation or school Achieved success in their chosen sport Had a positive and encouraging attitude that has inspired others Attended sessions with enthusiasm and energy Been an irreplaceable and vital component of the participant/s productivity and encouragement
Please proved further explanation (maximum 50 words)
3. The following relate to the nominee’s attitude and sportsmanship. The nominee has:Please select all that are applicable.
Been committed to providing the highest standard of coaching to their team players or individuals Given up a substantial amount of time to coach in local sport in any capacity Demonstrated a values-based approach to coaching Shown respect for the referee, players and opponents Shown good work ethic and ambassadorship for their sport Shown a commitment to personal and team development, or supporting the development of others Been committed to supporting their team in games, matches and meets Given their full capacity and effort Acted as a mentor for other coaches Acted in a voluntary capacity
Please provide further explanation (maximum 50 words)
4. Does the nominee identify as having a disability?
5. Please summarise the nominee’s achievements in 150 words or less.
You may attach supporting evidence (no more than three A4 pages)(Allowed file types:gif|png|jpg|jpeg|pdf & file size max 2mb)
Please upload one – two photos of the nominee.(Allowed file types:gif|png|jpg|jpeg & file size max 2mb)
First Name :
Last Name :
Relationship to nominee (ie. Family member, colleague, coach, organisation) :
Before you submit your nomination, please print a copy for your records
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