Gippstar Monthly Nomination Form

Gippstar Monthly Nomination Form

Please complete all sections that apply and attach any relevant supporting documents and photos. Guidelines can be found here:
Nominator Details
Date

DayMonthYear
Date
Name of Nominator

First NameLast Name
Nominator’s Contact Email
example@example.com
Nominator’s Contact Mobile
Please enter a valid phone numberFormat: 0000 000 000.
Relation to Nominee
Nominee Details
Nominee Details: Please provide the nominee’s information as accurately as possible.
Nominee Category
Note: Any athlete of any age can be awarded the "Open Age" Gippstar Award if they achieve the highest number of points given by the Gippstar Panel.
Nominee Name

First NameLast Name
Sport
Date of Birth

MonthDayYear
Date
Age at 30th June
Address

Street Address

Street Address Line 2
TownPost Code
Nominee Contact Email
example@example.com
Nominee Contact Mobile
Please enter a valid phone number.Format: 0000 000 000.
Competition Achievements

Please provide detailed information on up to 3 recent events (most recent first) which the athlete has competed in, to be considered for this nomination.
Event 1 Name
Date

DayMonthYear
Date
Level of Competition
If Other - please state
Grade
(u12, open, etc)
Was it an Open Event?
Was it a Schools Competition?
Competed as
If Other - please state
Result
E.g. Individual Result (Gold, Silver etc); Team Result (Premiers, Runners up, Gold etc)
Personal Best / Milestone Achieved
Contribution to Team Performance
Brief Description of Event
Event 2 Name
Date

DayMonthYear
Date
Level of Competition
If Other - please state
Grade
(u12, open, etc)
Was it an Open Event?
Was it a Schools Competition?
Competed as
If Other - please state
Result
Personal Best / Milestone Achieved
Contribution to Team Performance
Individual Result
Team Result
Brief Description of Event
Event 3 Name
Date

DayMonthYear
Date
Level of Competition
If Other - please state
Grade
(u12, open, etc)
Was it an Open Event?
Was it a Schools Competition?
Competed as
If Other - please state
Result
Personal Best / Milestone Achieved
Contribution to Team Performance
Individual Result
Team Result
Brief Description of Event
Other Sporting Achievements

Please outline any of the following where relevant: Significant improvement or reached a personal best; Displayed leadership or sportsmanship; Overcame adversity, injury,or personal challenge; Contributed to team morale, development, or mentoring; Represented club/region/state in a positive and professional manner.
Achievement 1
Achievement 2
Achievement 3
Community & Character Contributions

Involvement in community programs, volunteering, or mentoring; Acting as a role model or ambassador for their sport; Balancing sport with study/work responsibilities; Other notable contributions.
In 50 words or less describe the athlete's contributions(as per above).
Eligibility & Membership Confirmation

To our knowledge, the nominee:
The nominator has read the Gippstar selection criteria guidelines
The nominee is a member of a local sporting association/club
Has the nominee previously received a Gippstar Award
The Nominee complies with residential criteria
The nominee is currently a University student at:
Name of University
Gippsland Residential Address

Street Address

Street Address Line 2
CityStatePostal Code
Additional Information
Additional Information
Additional Comments
To assist with the media release announcing the monthly winners, please upload two high resolution files below. These will also be used on our Webpage and social media sites *

From time to time, print and television media may also wish to contact nominees for interviews. If you do not wish to be contacted by the media, please notify Jude Bergmann (03) 5127 0174 or via judeb@sportgippsland.org.au.
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Gippstar Monthly Nomination Form

Nominator Details

Nominee Details

Competition Achievements

Other Sporting Achievements

Community & Character Contributions

Eligibility & Membership Confirmation

Additional Information