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 participated: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 considerable improvements in their performances and achievements Achieved success in their chosen sport Made a significant impact in their sport or club
Please provide 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.
Displays sportsperson-like conduct on and off the playing area Collectively shown respect for the coach, referee and their opponents Shown good work ethic and ambassadorship for their sport
4. 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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