Nomination Form

Nominate one of the categores below. (Click here to view Categories info)
Category may be changed at the discretion of the KIC Committee

• Peer Support - Div1
  Peer Support - Div2
  Community Support - Div1
  Community Support - Div2
  Indigenous Youth Support - Div1
  Indigenous Youth Support - Div2
  Homeless Youth Support - Div1
  Homeless Youth Support - Div2
  Against All Odds - Div1
  Against All Odds - Div2
  Role Model
  Mentor
  Group or Individual Supporting Youth
  

Nominee Details

• Name*
• Address*
• Town*
• Postcode*
• Home Phone
• Work Phone
• Mobile*
• Email*

Nominated by

• Your Name*
• Your Email*

• Address*
• Town*
• Postcode*
• Home Phone*
• Work Phone*
• Mobile *
• Relationship
• Organisation

Referee details

• Name
• Phone
• Mobile

Permission to use Image

In accordance with National and State Privacy and Personal Information Protection legislation and principles, including the "NSW Privacy and Personal Information Protection Act 1998" and "The Privacy Act 1988" (Cth), I permit Kids in Community Inc to keep, store and use photographs of me/our group taken or provided, for advertising and promotional purposes, specifically in relation to the Kids in Community Awards. I understand that this may include printed and electronic publications.

Agree

Please attach nominee photo here (No larger than 2MB please).

Or click here to email us the photo – Don't forget to include nominator's name and name of nominee in photo.

Questions Regarding the Nominee

Please be as clear and concise as possible.

1. Why do you think the person/group you have nominated should receive an award for the category you have chosen?  (max 200 words) Read through the category description and ensure your nomination addresses the specific criteria for that category.

2. In relation to the specific category, what do you think inspires or drives the nominee?

3. If the nominee has supported any particular group/s or individual/s please list (include approximate hours per week), otherwise, if not relevant to the nominated category, indicate "not applicable"

4. If the nominee has been awarded any recent certificates of achievement or recognition relevant to the nominated category, please list; otherwise indicate "not applicable". Please do not submit copies of certificates.

5. What is the occupation of the nominee?

----- PLEASE SELECT ----- High School Student TAFE Student Uni Student Working Full Time Working Part Time Unemployed

IMPORTANT: Prior to submitting please PRINT THIS PAGE for your own records. Once submitted you will no longer have access to this form.