Kellion Victory Medal Scheme

Kellion Victory Medal Scheme

Application Form
PART A

Applicant details
Name*
Maiden / given name (if applicable)
Name you wish printed on the Kellion certificate*
Home address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Email*
example@example.com
Mobile phone*
Please enter a valid phone number.
Home phone
NDSS number
Membership number (if applicable)
Date of birth*

DayMonthYear
PART B Medical Information

Current doctor / specialist (who may be contacted to help verify your diagnosis date)
Full Name*
Position*
Phone Number*
Please enter a valid phone number.
Diagnosis Month*
Diagnosis Year *
Please provide a brief comment as to how you know of your diabetes diagnosis date.*
Note: please include separately any supporting documents that can verify the date of diagnosis eg., hospital admission forms, test results, letters from doctors / specialists, also any statements from family members etc. Sometimes life events (eg., family member birthday, etc.) can help to verify a recollection of the diagnosis date.
PART C Consent

I hereby given permission for a representative of the Kellion Advisory Committee, to access information from my medical records regarding my eligibility for a Kellion Victory Medal.
Applicants signature*

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Date*

DayMonthYear
PART D Short Story

Please provide a short story on your experiences living with diabetes. The following headings are provided as a guide only. Please feel free to tell your story in your own way.
Tell us about your diagnosis and, if possible, describe your family and experiences at this time.*
How did you manage in your early years following diagnosis?*
What technologies and/or improvements in treatment have aided you the most?*
Most important people who helped you manage and how?*
What are some of the best achievements in your life?*
What does this medal mean to you?*
PART E Media Consent

I hereby consent to Diabetes Australia & Diabetes Victoria using my written story and photograph/video in media, reports, and online media to promote the Kellion Victory Medal Scheme.
Applicants signature

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Date

DayMonthYear
Consent Signed - HIDDEN
PART F Nomination for supporter applicant
Name of Kellion Victory Medal applicant

First NameLast Name
Name of nominated supporter

First NameLast Name
Supporter’s relationship to medal applicant
Date support started

DayMonthYear
What makes them special
Supporter contact details
Email
example@example.com
Home phone
Please enter a valid phone number.
Mobile phone
Please enter a valid phone number.
Kellion Victory Medal applicant signature*

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Date

DayMonthYear
Kellion Medal Record
Should be Empty:

Kellion Victory Medal Scheme

PART A

PART B Medical Information

PART C Consent

PART D Short Story

PART E Media Consent

PART F Nomination for supporter applicant

Supporter contact details