Nomination form - WordPress â www.wordpress.com
Nomination form - WordPress â www.wordpress.com
Nomination form - WordPress â www.wordpress.com
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<strong>Nomination</strong> <strong>form</strong><br />
“We are Queenslanders – we’re the people they breed tough north of the border. We’re the ones that they knock down<br />
and we get up again. This weather may break our hearts, but it will not break our will.” Anna Bligh, Premier of Queensland (January 2011)<br />
<strong>www</strong>.queenslandweek.qld.gov.au
Message from the Premier of Queensland<br />
I want to say a personal, heartfelt thank you to everyone who<br />
has assisted in the recovery and rebuilding efforts following<br />
the devastating effects of the 2010–11 Queensland floods and<br />
Tropical Cyclone Yasi. Your response has been overwhelming.<br />
The scars are going to take a long time to heal for many of us<br />
and the road to recovery will be a long one. But while these<br />
disasters broke our hearts they did not break our will. Stories<br />
of the amazing Queensland spirit have emerged. We have seen<br />
a ‘mud army’ of volunteers taking to the streets and countless<br />
stories of bravery and self-sacrifice.<br />
We have learned that Queenslanders are ready to pull together, ready to fight for each other,<br />
ready to help their neighbour and sometimes ready to risk their lives to save others. In 2011,<br />
Queensland Week will be held from 4–13 June and will be dedicated to recognising the<br />
<strong>com</strong>munity heroes of these extreme and devastating weather events.<br />
This program will recognise individuals who have shown outstanding <strong>com</strong>munity initiative,<br />
bravery, courage, resilience and strength during the greatest natural disasters of our history.<br />
I also want to sincerely thank all the police, emergency services and Australian Defence<br />
Force personnel. Each one of these workers has shown immense courage and spirit<br />
during Queensland’s darkest hour. They too will be honoured through their own official<br />
recognition ceremonies.<br />
<strong>Nomination</strong>s close on Friday 1 April 2011 and I encourage you to put pen to paper and<br />
nominate someone in your <strong>com</strong>munity whose heroism has inspired you.<br />
Each nominee will receive a <strong>com</strong>memorative medal and will be publicly recognised for their<br />
hard work, at local events in each of the affected regions during Queensland Week.<br />
I look forward to sharing this very special Queensland Week with our disaster heroes.<br />
ANNA BLIGH MP<br />
PREMIER OF QUEENSLAND
Official nomination <strong>form</strong><br />
Heroes are those people who have shown outstanding <strong>com</strong>munity<br />
initiative, bravery, courage, resilience and strength during the<br />
2010–11 Queensland floods and/or Tropical Cyclone Yasi.<br />
Entries close Friday 1 April 2011. The heroes will be announced<br />
publicly during Queensland Week (4–13 June 2011).<br />
Nominee’s details (the person you wish to nominate)<br />
If possible, please send an image of your local hero with their<br />
name by email to heroes@premiers.qld.gov.au. The image will not<br />
be used for any purpose without the individual’s permission.<br />
Nominator (your details)<br />
Name:<br />
Position/organisation (if applicable):<br />
Address:<br />
Name:<br />
Position/organisation (if applicable):<br />
Suburb:<br />
State:<br />
Address:<br />
Postcode:<br />
Email:<br />
Contact phone number:<br />
Suburb:<br />
Postcode:<br />
Contact phone number:<br />
Email:<br />
Reason for nomination (100 words)<br />
State:<br />
Relationship to nominee:<br />
How did you find out about the Queensland Disaster Heroes<br />
program? Please specify:<br />
Nominator declaration<br />
I hereby declare that I have submitted the nomination in accordance<br />
with the Queensland Disaster Heroes conditions for nomination<br />
and confirm that, to the best of my knowledge, the in<strong>form</strong>ation<br />
I have provided in this nomination is accurate, factual, <strong>com</strong>plete<br />
and up-to-date. I agree that the State of Queensland may use<br />
and disclose my personal in<strong>form</strong>ation in the manner set out<br />
in the Queensland Disaster Heroes conditions for nomination.<br />
Signature<br />
Date<br />
Endorsement<br />
This nomination has been endorsed by<br />
Name<br />
Position<br />
Organisation<br />
Please nominate the region where the nominee demonstrated<br />
heroic behaviour.<br />
Cairns and Cassowary Coast<br />
Rockhampton / Theodore<br />
Bundaberg / Gympie<br />
Toowoomba / Western Downs<br />
Brisbane<br />
Townsville<br />
Emerald<br />
Lockyer Valley<br />
Ipswich<br />
Signature<br />
<strong>Nomination</strong>s must be endorsed by a local councillor, state or federal MP, emergency<br />
services or ADF personnel, police officer, public servant or charity worker.<br />
Please forward your nomination to:<br />
Post: Queensland Disaster Heroes<br />
Department of the Premier and Cabinet<br />
PO Box 15185<br />
City East QLD 4002<br />
Email: heroes@premiers.qld.gov.au Fax: 07 3224 4065<br />
Entries close Friday 1 April 2011.<br />
For more in<strong>form</strong>ation visit <strong>www</strong>.queenslandweek.qld.gov.au<br />
Thank you for your generous donations to the Premier’s Disaster<br />
Relief Appeal. You can still make a difference by donating to the<br />
Appeal at <strong>www</strong>.qld.gov.au/disasterappeal<br />
Date
Conditions of nomination<br />
1. Heroes are those people who have shown outstanding <strong>com</strong>munity initiative, bravery, courage, resilience and strength during the 2010–11<br />
floods and/or Tropical Cyclone Yasi.<br />
2. <strong>Nomination</strong>s must be submitted by persons 18 years of age or over.<br />
3. <strong>Nomination</strong>s must be received on an official nomination <strong>form</strong> with all questions <strong>com</strong>pleted.<br />
4. <strong>Nomination</strong>s must be endorsed by a local councillor, state or federal MP, emergency services or ADF personnel, police officer, public<br />
servant or charity worker.<br />
5. Supporting documentation submitted with nominations will be retained by the State of Queensland through the Department of the Premier<br />
and Cabinet (the department).<br />
6. The department’s decision is final on all matters relating to the nomination process and the selection of recipients,<br />
and no correspondence will be entered into.<br />
7. The department reserves the right to disclose the identity of the nominator to the nominee.<br />
8. The nominator’s and/or nominee’s name, image, statement or otherwise may be published and/or used in any <strong>form</strong> of media, in any<br />
context pertaining to the program. Personal in<strong>form</strong>ation about an individual will only be disclosed in this manner if the individual<br />
consents to such disclosure. Nominators are requested to sign the nominator declaration on the nomination <strong>form</strong> including the privacy<br />
consent. Individuals are free to give or withhold such consent at their discretion, however the department will be entitled not to accept a<br />
nomination, or to withdraw a nominee from consideration for the program at any time prior to the public announcement of winners, if the<br />
necessary consent is not provided.<br />
9. Recipients will be honoured with a medal. A person cannot receive more than one medal.<br />
10. Entries close 5pm Friday 1 April 2011.<br />
11. The department may change these conditions of entry or cancel or vary the program process at any time, whether before, on or after the<br />
closing date.<br />
Privacy in<strong>form</strong>ation<br />
The Department of the Premier and Cabinet (the department) is collecting your personal in<strong>form</strong>ation in accordance with the In<strong>form</strong>ation<br />
Privacy Act 2009 (Qld), in order to coordinate/administer the Queensland Disaster Heroes program (the program) and any events in<br />
connection with the program. The in<strong>form</strong>ation will be stored securely and accessed only by the department’s authorised employees for the<br />
purposes specified above, or for the purpose of contacting you regarding future Queensland Disaster Heroes, or other programs and events<br />
administered by the department. Personal in<strong>form</strong>ation may be disclosed to third parties as specified in the conditions of nomination for the<br />
program. Your personal in<strong>form</strong>ation will not be disclosed to any other third party without your consent, unless authorised or required by law.<br />
If at any time you would like your personal in<strong>form</strong>ation removed from our database, please send your request to<br />
heroes@premiers.qld.gov.au or fax to 07 3224 4065.<br />
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