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 level Regional level State level National level International level
2. The following relate to the nominee’s attitude and sportsmanship. The nominee has:Please select all that are applicable.
Given up a substantial amount of time to volunteer in their sport Been a role model for others Shown respect for the coach, referee and players Shown good work ethic and ambassadorship for their sport Shown a commitment to personal development, or supporting the development of others Joined the volunteering program out of genuine will? (not out of compulsory requirement) Acted as a mentor for other volunteers
Please provide further explanation (maximum 50 words)
3. Does the nominee identify as having a disability?
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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