Consumer Achievement Award - Nomination Form

Victorian Homelessness Achievement Awards Consumer Achievement Award - nomination form

The 2015 Victorian Homelessness Achievement Awards will celebrate the exceptional efforts of specialist homelessness services, consumers and other community members to end homelessness in Victoria. About the Consumer Achievement Award This award will recognise an individual who has experienced homelessness and has made an outstanding contribution to improve the lives of others experiencing homelessness in Victoria. Instructions and timelines If you would like to nominate a consumer for the award, please complete the attached form. Please note that members of the judging panel, their organisations and immediate family cannot nominate or be nominated for an award. The activity or activities for which the nominee is being recommended must have taken place at some point between 1 January 2013 and 31 December 2014. Activities that commenced, were in progress, or were completed over this period are all eligible. You can type directly onto this form, or print the form off and fill in the details by hand. Please scan and send completed forms to [email protected], or mail to: Awards 2015 Council to Homeless Persons 2 Stanley Street Collingwood VIC 3066 In order to be eligible for consideration, nomination forms must complete all fields and be received by 5pm, Wednesday 15 July 2015. CHP will acknowledge receipt of nominations within five working days. Judging and award presentations A panel of consumer, sector and government representatives will assess the nominations. The awards will be presented at the CHP Statewide Homelessness Conference 2015, on Thursday 17 September 2015.

If you would like more information about the awards or assistance in completing the nomination form, please contact Trish Westmore, Capacity Building and Policy Officer, on 03 8415 6207 or via email at [email protected].

1 Part 1: Your details Name: Organisation: Position: Address: Telephone: Email:

Part 2: Nominee’s details Please provide the nominee’s contact details.

Name: Address: Telephone: Email:

Has this nominee been formally recognised through any other awards or commendations? ☐ No. ☐ I’m unsure. ☐ Yes. Please provide details:

Part 3: Experience of homelessness Please provide a brief description of the nominee’s experience of homelessness.

Part 4: About the nominee In no more than 200 words, please describe the activity or activities for which this person is being nominated.

2 Part 5: Helping others In no more than 100 words, please describe how the nominee has made a significant effort to support other consumers who have experienced homelessness (eg volunteering, providing practical support, encouraging consumer participation). Please provide examples and describe where and when these activities took place and who they were targeted towards. You can use dot points on this form.

Part 6: Community education In no more than 100 words, please describe how the nominee has contributed to educating the community about the lived experience of homelessness (eg sitting on advisory groups, sharing their story, art or media projects). Please provide examples and describe where and when these activities took place and who they were targeted towards. You can use dot points on this form.

3 Part 7: Improving services/responses In no more than 100 words, please describe how this nominee has contributed to improving services or improving responses for people who are experiencing homelessness (eg advising programs or agencies, participating in research projects). Please provide examples and describe where and when these activities took place and who they were targeted towards. You can use dot points on this form.

Part 8: Referee details Please provide the details of two referees who can be contacted about this nomination.

Name: Organisation: Position: Telephone: Email:

Part 9: Declarations Please ensure that the declarations below have been signed by the nominee and yourself.

Nominee or key contact person’s declaration I agree to be nominated for a 2015 Victorian homelessness achievement award. I agree that the Council to Homeless Persons or its agents may use the information provided in this form to assess nominations for the awards and for publicity purposes associated with the awards. I consent to the Council to Homeless Persons or its agents contacting the people named in this form and seeking comment from them regarding this nomination. I acknowledge that the Council to Homeless Persons will store this information securely.

4 Name: Signature:

Your declaration: By submitting this nomination for the Victorian homelessness achievement awards I certify that all information provided is true and correct to the best of my knowledge. I agree that the Council to Homeless Persons or its agents may use the information provided in this form to assess nominations for the awards and for publicity purposes associated with the awards. I consent to the Council to Homeless Persons or its agents contacting the people named in this form and seeking comment from them regarding this nomination. I acknowledge that the Council to Homeless Persons will store this information securely.

Name: Signature: