Impetus 08 - Geelong Youth Awards

Fields marked with need to be completed
Details of young person or group being nominated:
	Given Name:
	Surname:
	Address:
	Suburb:
	Post Code:
	Date of Birth:
	Day Phone:
	Mobile Phone:
	Email Address:
	Occupation or Educational Institution:

Nomination Details
	This nomination is for: (more than one box may be ticked)
	Leadership Award	Positive Image Award
	Citizenship Award	Environment Award
	Inspiration Award	Active Achievement
	Outstanding Youth Organisation / Group	Cultural/Arts
	Youth Worker	Voluntary Award - Working with Young People

	Is the nominee aware of this nomination?	Yes No
	Details of person nominating:
	Given Name:
	Surname:
	Relationship to nominee:
	Address:
	Suburb:
	Post Code:
	Day Phone:
	Mobile Phone:
	Email Address:
	How did you hear about the Awards?
	Reasons for nomination:


Referee Details
Referees (minimum of two referees). Please note referees and nominators may be contacted to provide further information.
Referee #1		Referee #2
Name:		Name:
Contact Number:		Contact Number:
Relationship to Nominee:		Relationship to Nominee:

Declaration
I declare that the information provided in this form is true and correct. The personal information being collected on this form is for council purposes which will be solely used for this primary purpose or directly related purposes. In addition, the informant understands that they may apply to council for access and/or amendment of the information. This information will not be disclosed except as required by law. The City of Greater Geelong produces a number of print and web-based publications each year, such as the Annual Report, City Plan, community newsletters, and information contained on our web site www.geelongaustralia.com.au To illustrate these and other Council communications, the City often requires photographs to be taken of people in public places, at events, or using Council facilities or services.
YES