Nomination Form

Nominate check ONE category only. (Click here to view Categories info)
Nominated category may be changed at the discretion of the KIC Committee

Items marked with* MUST BE completed

• Young People Supporting

  1 - Youth in General
  2 - Indigenous Youth
  3 - Diverse Youth
  4 - Community

  Young People Achieving

  5 - Role Models
  6 - Against All Odds

  Young People Supporting

  7 - Individual Mentors
  8 - Supporting Groups
  9 - Media Reporting

Nominee Details

• Name*
• Age* 13 14 15 16 17 18 19 20 21 22 23 24 25 26+
• Address*
• Town*
• Postcode*
• Home Phone*
• Work Phone
• Mobile
• Email*
• School, Group, Organisation*

Nominator's Details

• Your Name*
• Age* selected="selected"> 13 14 15 16 17 18 19 20 21 22 23 24 25 26+
• 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.

Nominee's Contribution

Please be as clear and concise as possible.

1. Why do you think the person/group you have nominated should receive an award in your chosen category?  (max 200 words) Read through the category description and tailor your nomination accordingly.
MEDIA Reporting Nominees - Give details of where and when stories appeared & attached copies (Max of 3).

2. How much do you think the nominee’s contribution does each of the following? They don’t need to contribute to all of them. Please select a number for each question and make a comment or give an example – to explain your rating.

Please rate the following (1 = Not at all, 10 = extremely).

Rate 1 2 3 4 5 6 7 8 9 10 Inspires, engages or includes other young people

Rate 1 2 3 4 5 6 7 8 9 10 Helps more disadvantaged or excluded groups or individuals

Rate 1 2 3 4 5 6 7 8 9 10 Makes an impact in their community

Rate 1 2 3 4 5 6 7 8 9 10 Goes beyond their normal school or work activities

Rate 1 2 3 4 5 6 7 8 9 10 Fosters better relationships between different social, ethnic or cultural groups

3. Please describe any personal challenges faced by the nominee? These details are used for judging purposes only and will be kept confidential.

4. How much do you feel being nominated for a KIC award will benefit the nominee’s self-esteem and confidence?
Please select an answer select Not much A little Quite a bit Very much

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