2014/2015 Breaka U14 Junior Surf Lifesaver of the Year
Nomination Form
Name
Club
Branch
Three key achievements
from the past season (Please

enter in dot point form)
Please attach a photo of the Nominee (jpeg)
Surf Life Saving Queensland
18 Manning Street
South Brisbane QLD 4101
PO Box 3747
South Brisbane QLD 4101
t. +61 7 3846 8000
f. +61 7 3846 8008
w. lifesaving.com.au
ABN 27 360 485 381
Nomination: Essential Information
Please provide proof via a print out form from SurfGuard or additional documentation:
1. Current active, financial member of Surf Life Saving Australia
2. Member in the U8 – U14 age group
3. Surf Life Saving awards/certificates held, if any
4. Community awards/certificates held
5. Patrolling hours (rostered and volunteer) for 2012/2013, and 2013/2014, seasons if any
Surf Life Saving Queensland
18 Manning Street
South Brisbane QLD 4101
PO Box 3747
South Brisbane QLD 4101
t. +61 7 3846 8000
f. +61 7 3846 8008
w. lifesaving.com.au
ABN 27 360 485 381
Nomination: Selection Criteria
Please answer the selection criteria under the following headings for the preceding 12 months:
1. Describe nominee’s involvement in Junior Activities during the 2014/2015 season
2. Explain nominee’s background within Surf Life Saving
3. Personality and general attitude of nominee
4. Achievements and awards received within Surf Life Saving and the community
5. Past, present and future contributions to Surf Life Saving
6. Ambitions and goals in Surf Life Saving
7. Explain why this member is worthy of this award? (200 words or less)
Surf Life Saving Queensland
18 Manning Street
South Brisbane QLD 4101
PO Box 3747
South Brisbane QLD 4101
t. +61 7 3846 8000
f. +61 7 3846 8008
w. lifesaving.com.au
ABN 27 360 485 381
Nomination: Contact Details & Endorsement




Complete all fields on the nomination form using the electronic format only. This document must be typed not
handwritten
Ensure this document is completed in full and submitted to your Branch by 9 February 2015
Ensure a digital photograph on also submitted as an attachment, along with the photo of the front cover of this
nomination form.
Ensure the Nominator, Club & Branch sections are signed as a declaration of the information provided is true correct
and supported.
Nominee’s Contact Details
Name
Nominee’s Membership Category
Postal Address
Contact Number
Email Address
Shirt Size
Nominator’s Contact Details
Name
Club (If Applicable)
Position/s held (If Applicable)
Postal Address
Contact Number
Email Address
ENDORSEMENTS
NOMINATOR’S ENDORSEMENT
Nominator’s Signature
Date
CLUB ENDORSEMENT
Club Name
Club President Name
Club President Signature
Date
BRANCH ENDORSEMENT
Branch Name
Branch President Name
Branch President Signature
Date
Surf Life Saving Queensland
18 Manning Street
South Brisbane QLD 4101
PO Box 3747
South Brisbane QLD 4101
t. +61 7 3846 8000
f. +61 7 3846 8008
w. lifesaving.com.au
ABN 27 360 485 381