Youth Initiative Award Nomination Form

Nominee Information

Details of the person being nominated

Name(Required)

First Last

Age (must be under 25)(Required)

Address(Required)

Street Address Town/suburb State Post code

Enter Email Confirm Email

Phone number(Required)

Nominee’s must live, study or work in the Upper Yarra region defined as postcodes of 3799 and 3797 and the towns of Hoddles Creek, Launching Place and Don Valley

Live in the Upper Yarra region?

Yes

Study in the Upper Yarra region?

Yes

Work in the Upper Yarra region?

Yes

Other? Please specify here

Nominee's link to the community(Required)

Please list clubs, organisations or groups where community contributions have been made and include role (example; Club Captain, Yarra Junction Junior Netball Club; Student Representative Council member, Warburton Primary School)

Nominator Information

Details of the person making the nomination

Name(Required)

First Last

Address(Required)

Street Address Town/suburb State Post code

Email(Required)

Enter Email Confirm Email

Phone number(Required)

RELATIONSHIP TO NOMINEE You must be a teacher, employer, coach, mentor, committee member or other individual who has worked directly with the nominated person in a community capacity and recognises their potential

Employer

Yes

Teacher

Yes

Coach

Yes

Mentor

Yes

Further details

E.g. of you selected Employer specify the organisation's/company name.

Other? Please specify here

Please detail the reasons why you are nominating this person. How have they made, or continue to make a positive contribution to the community for the benefit of others?

How has the nominee used their initiative to improve their community?(Required)

What difference have the nominee's efforts made to others?(Required)

What impact have the nominee's efforts had on their own personal development?(Required)

Why do you think this young person should win this award?(Required)