South Australian Sport
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2017 South Australian Sport Hall of Fame General Member Nomination Form
Few nations have a more remarkable sporting tradition than Australia and our South Australian champions are certainly up there with the best.
For more than 100 years they have proudly represented their State and Country on the international arenas of sport and through their on-field deeds and lifestyle values have become part of our inspirational sporting folklore.
Sadly, the courage and determination of these great champions has been buried in dust covered books and fading memories. All that has now changed with the establishment of the South Australian Sport Hall of Fame.
An initiative of Sport SA, a new chapter will be written into the history books of sport in this State and I have proudly accepted the challenge to Chair the Board of Governors.
Robert Gerard AO Chairman, Board of Governors The South Australian Sport Hall of Fame
Pre Nomination Declaration All persons put forward to the Hall of Fame Selection Committee must first agree to sign the below statement: I hereby declare that throughout my sporting and personal life I have most strongly identified with South Australia as the state I belong to. All information in this nomination is true and correct.
………………………………. Signature of Nominee Date
…………………………………. Name of Independent Witness
…………………………………. Signature of Independent Witness Date
Please ensure you have completed the declaration above.
Nominations close 5pm Friday July 14th 2017. Late entries will not be considered.
How to submit completed form: Via email to Peter Spry: [email protected] Via post: The South Australian Sport Hall of Fame PO Box 103, WEST BEACH SA 5024 For more details please visit www.sportsa.org.au .
Section 1: Details of Nominee and Nominator
- 1 - Nominee details:
Title Mr Mrs Miss Ms
Family Name: Given Name(s): Post nominals (if any):
Maiden Name (if appropriate):
Date of Birth: Date of Death (if applicable): Place of Birth (City and State):
Address: Suburb: State: Postcode:
Phone (H): B): Mobile:
Email Address:
*Debut date of International Competition:
*Date of retirement from International Competition:
Signature: ……………………………… Date: (Nominee or authorised family representative)
Nominator details:
Title Mr Mrs Miss Ms
Family Name: Given Name(s): Post nominals (if any):
Organisation Name (if appropriate):
Business Address: Suburb: State: Postcode:
Phone (H): Mobile: Email Address:
Signature: ……………………………… Date: (Nominator)
Section 2: International Achievements
Name of Sport: - 2 - Involvement: Administration Coaching Training Sports Science Sports Medicine Media History Umpiring Refereeing Judging Other:
Mere long service or involvement in sport is not sufficient justification for selection without demonstrating outstanding achievement arising from iniatiative or innovation. How many years were you involved at the International level? List the sport’s International Competitions in order of importance:
1:
2:
3:
4:
List your International achievements at these events in order of importance:
Year Competition Result
List International Awards and Honours:
1:
2:
3:
4:
International Hall of Fame
Is there an International Hall of Fame for your sport?
When did it commence? Have you been inducted? If so, when?
Is there further recognition from induction in the Hall of Fame? If so, have you been recognised at this level?
Please list any other significant involvement in your sport at international level: Section 3: National Achievements – List in order of importance
Year Competition Result - 3 -
List National Awards and Honours:
1:
2:
3:
National Hall of Fame
Is there a National Hall of Fame for your sport?
When did it commence? Have you been inducted? If so, when?
Is there further recognition from induction in the Hall of Fame? If so, have you been recognised at this level?
Please list any other significant involvement in your sport at national level:
Section 4: State Achievements – List State Awards and Honours:
1:
2:
State Hall of Fame
Is there a State Hall of Fame for your sport?
When did it commence? Have you been inducted? If so, when?
Is there further recognition from induction in the Hall of Fame? If so, have you been recognised at this level?
Please list any other significant involvement in your sport at State level:
Has the nominee been subject to disciplinary measures by the national sporting organisation? If so please provide details:
- 4 -