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. At what level does the initiative operate?Please select all that are applicable.
Metro (Melbourne) Regional State
2. When was the initiative/program established?
3. Is there a member of the project team that identifies as having a disability?
4. Please provide a summary of the initiative and its impact, including how it is sustainable. Minimum 300 words, maximum 600 words.
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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