Bravery Medal Nomination Form

Bravery Medal Nomination Form

Surf Life Saving Queensland
SLSQ and its members are committed to saving lives and continually working towards its vision of ‘zero preventable deaths in Queensland public waters’. Surf Life Saving Queensland(SLSQ) is the State’s peak beach safety and rescue authority comprising of 58 surf life saving clubs, 80 lifeguard services and close to 35,000 dedicated individuals (volunteers and staff).

The Surf Life Saving Queensland Bravery Medal (SLSQBM) has been introduced to members of the association and/or the community who have who selflessly put themselves in jeopardy to protect the lives of others.

Bravery or courage differs from fortitude in a crisis situation. Bravery is a deliberate choice to go from a place of safety to danger or remain in a perilous position to provide help.

Who may make a nomination?

Anyone may make a nomination by completing by the nomination form link below. For a list of Branch email addresses, please click here [DB1]

Who can be nominated?

Anyone may be nominated who meets the criteria above by the nomination form link below.

The nominee must have the nomination and supporting documentation endorsed by their relevant branch prior to it being submitted to SLSQ for review.

Need assistance?

If you required further information or have issues with the application, please email lifesavingoperations@lifesaving.com.au

SECTION 1 - Details of person submitting nomination
Please provide your contact details to enable officers of the SLSQ Life Members & Civil Honours Panel and Panel Secretary to seek further details if required.
Title (Mr. Mrs, Ms,Dr, etc) *
Name*

SurnameFirst Name
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Position/Title
SLSQ Club Name (please write NA if not affiliated with SLSQ)
SLSQ Branch Name (please select NA if not affiliated with SLSQ)
Home Phone Number
Please enter a valid phone number.
Mobile Number*
Please enter a valid phone number.
Email Address*
example@example.com

SECTION 2 - Nominees Information
Please tell us about the person you are nominating for the Bravery Award.

In some instances, a group of persons may have been involved in a single incident. When nominating multiple people, we require the details of each individual. Complete section one for each of the nominees.
Title (Mr. Mrs, Ms,Dr, etc) *
Name*

SurnameFirst Name
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Position/Title
SLSQ Club Name
SLSQ Branch Name*
SLSQ Branch Email*
example@example.com
Home Phone Number
Please enter a valid phone number.
Mobile Number*
Please enter a valid phone number.
Email Address*
example@example.com
Date of Birth

MonthDayYear
Date

SECTION 3 - Incident details
Date of the incident*

MonthDayYear
Time of incident (If know)*
Description of weather conditions (unusual or dangerous conditions)*
Please provide a summary of the rescue efforts elaborating on any elements of risk within the rescue (e.g. rescue from floods waters)*
ACTIVITIES UNDERTAKINED BY THE PERSON YOU ARE NOMINATING FOR AN AWARD

Please set out below details of the actions in which the person/s you are nominating was involved, and the reason why you consider he or she should receive special recognition by the award of an SLSQ Bravery Decoration
If possible please enclose photographs of the incident or of the place where it occurred. Additionally, you may also supply media articles and web links that provide further information and details of the incident.*
Please provided any supporting documentation for this section of the application*

Cancelof

SECTION 4

INCIDENT WITNESS INFORMATION

If there were persons/ eye witnesses who are able to direct comment on the incident.

Please note: While helpful, these details might not always be avaliable
How many witnesses were there
Witness 1
Title (Mr. Mrs, Ms,Dr, etc)
Name

SurnameFirst Name
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
SLSQ Club Name (please write NA if not affiliated with SLSQ)
SLSQ Branch Name (please select NA if not affiliated with SLSQ)
Home Phone Number
Please enter a valid phone number.
Mobile Number
Please enter a valid phone number.
Email
example@example.com
Involvement in the incident
Witness 2
Title (Mr. Mrs, Ms,Dr, etc)
Name

SurnameFirst Name
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
SLSQ Club Name (please write NA if not affiliated with SLSQ)
SLSQ Branch Name (please select NA if not affiliated with SLSQ)
Home Phone Number
Please enter a valid phone number.
Would you like this nomination to be considered for a Lifesaving Excellence Awards and SLSA Meritorious Award?
Mobile Number
Please enter a valid phone number.
Email
example@example.com
Involvement in the incident
Witness 3
Title (Mr. Mrs, Ms,Dr, etc)
Name

SurnameFirst Name
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
SLSQ Club Name (please write NA if not affiliated with SLSQ)
SLSQ Branch Name (please select NA if not affiliated with SLSQ)
Home Phone Number
Please enter a valid phone number.
Mobile Number
Please enter a valid phone number.
Email
example@example.com
Involvement in the incident

Submit
Declaration - please sign the below box to confirm that all information provided on this application is accurate and true to the best of your knowledge.

Clear
If required, you might be contacted for further information for the application. Please indicated below you consent*
Should be Empty:

Bravery Medal Nomination Form

SECTION 1 - Details of person submitting nomination

SECTION 2 - Nominees Information

SECTION 3 - Incident details

Witness 1

Witness 2

Witness 3

Submit