Shire of Harvey
Youth Award (12 - 25 years)
Nomination Form
Nominations close 4pm on Thursday 12th April 2018.
Please refer to the Honours and Award Guidelines prior to completing this form.
Nominations submitted via any of the following methods:
- Emailed: attach to an emailand send to
- Posted: Chief Executive Officer, Shire of Harvey, PO Box 500, Harvey WA 6220
- Submitted in Person: 102 Uduc Road, Harvey or 7 Mulgara Street, Australind
If you are posting or delivering a nomination, it should be contained in a sealed envelope clearly marked “Honours and Awards”.
If you have any questions, please contact the Shire’s Community Development Officer – Stella Johnson on 9729 0308 or email
Name of Nominee
AddressSuburbPostcode
Home TelephoneMobile
Age of Nominee on 30th March 2018 (must be 12-25 years inclusive)
Your Name
AddressSuburbPostcode
Home TelephoneMobile
Is the nominee aware of the nomination?
YesNo
Shire of Harvey
Youth Award (12 - 25 years)
Selection Criteria
If you require more space for your answers please attach a separate page.
Residency
How long has the nominee been a resident of the Shire of Harvey?
Community Service
Briefly describe the nature of the nominee’s service to the community including the following details:
- Name of organisation(s) served
- Type of service provided by the organisation
- Length of service
- Position(s) held in organisation
- Involvement in events
What contributions and benefits has the nominee made to the community during the past year or a number of years?
How is the nominee involved in the wider community?
For example: Sports, school, arts, clubs etc.
How has the nominee shown leadership skills?
For example: Leadership / mentoring roles, role modeling for peers, encouraging participation of peers etc.
Has the nominee received any previous honours / awards? If so, please describe below.
Include samples of press articles, awards, certificates etc.