© 2018 - Victorian Aboriginal Child Care Agency
Graphic design by Reanna Bono
Community Leaders Award Nomination Form
Nominee Details
Name
*
Address
*
Street Address 1
Street Address 2
City
State
Post code
Phone
*
Email
*
Is the deadly person you are nominating Aboriginal and/or Torres Straight Islander living in Victoria?
*
Yes
No
The Mollie Dyer Awards is celebrating Victorian Aboriginal peoples dedication and leadership in the field of Aboriginal child and family services.
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Where does the nominee work?
*
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Please provide a brief bio of the nominee
*
This will be used on social media and websites if the nominee is successful in becoming a finalist and winner.
Nominator Details
Name
*
Phone
*
Email
*
A confirmation email will be automatically sent to this email address once the nomination has been submitted.
Organisation
*
Are you nominating on behalf of an organisation? Have you received approval to do so?
*
Yes
No
Relationship to the nominee
*
Referee Details
Name
Phone
Email
Organisation
Relationship to the nominee
Statement of support for the nominee to be awarded the Mollie Dyer Award for the Community Award
Community Award Details
Where does the nominee work?
*
How has the nominee shown leadership, advocacy, inspired positive change and worked to strengthen Aboriginal children and families?
*
500 characters max or 2 minute video Response can be written or submitted via video
Video response
If you are having difficulties uploading your video just contact us at awards@vacca.org