MIRAnominationform

M.I.R.A. Maribyrnong Inclusive Recognition Awards Reflecting Our Community

Maribyrnong City Council Phone: 9688 0200 Fax: 9687 7793 Email: email@maribyrnong.vic.gov.au After Hours/Emergency: 9688 0363 Postal address: PO Box 58, Footscray VIC 3011 Street address: Maribyrnong Council Offices Corner Hyde & Napier Streets Footscray VIC

www.maribyrnong.vic.gov.au

M.I.R.A

M.I.R.A. Maribyrnong Inclusive Recognition Awards Reflecting Our Community The MIRA recognises individuals, groups, businesses and not for profit organisations that have contributed to improving the quality of life of people with a disability within the City of Maribyrnong.

Nominations close on Friday 8 October 2010.

Indigenous and multicultural disability and community groups are strongly encouraged to nominate volunteers, staff and programs for the Awards.

A selection panel comprised of people with experience in the disability and community sectors, and including people with disabilities will assess the nominations.

The awards will be presented by special guests, at the awards celebration to be held on Friday 3 December, to coincide with International Day of People with Disability.

Maribyrnong City Council Phone: 9688 0200 Fax: 9687 7793 Email: email@maribyrnong.vic.gov.au After Hours/Emergency: 9688 0363 Postal address: PO Box 58, Footscray VIC 3011 Street address: Maribyrnong Council Offices Corner Hyde & Napier Streets Footscray VIC

www.maribyrnong.vic.gov.au

M.I.R.A

Award Categories Inclusive Business Practices Award – recognising a local Maribyrnong business or organisation that promotes inclusion in their service and facilities. For Example, offers good access, offers employment opportunities or promotes an inclusive environment.

Personal Achievement Award – recognising a person with a disability who has made a significant achievement in any aspect of their personal life. This can include education, employment or any other aspect of their life.

Arts Individual Award – recognising a person with a disability, who has undertaken an arts project or engaged in an aspect of the arts.

Arts Group Award – this award recognises mainstream arts groups who have been inclusive in their practice

Sporting Achievement Award – Individual – recognising a person with a disability, who lives or plays their sport in the municipality.

Sporting Achievement Award – Sporting Club - recognising the achievement of organisations that are welcoming and inclusive of people with a disability, and have accessible and inclusive activities. As well as sports clubs, this award is open to other not for profit organisations that offer physical activities and active recreation to people with a disability.

Volunteering Award – This award recognises individuals with or without a disability working in a voluntary capacity to improve access and inclusion for people with disability within the wider local community

Maribyrnong City Council Phone: 9688 0200 Fax: 9687 7793 Email: email@maribyrnong.vic.gov.au After Hours/Emergency: 9688 0363 Postal address: PO Box 58, Footscray VIC 3011 Street address: Maribyrnong Council Offices Corner Hyde & Napier Streets Footscray VIC

www.maribyrnong.vic.gov.au

M.I.R.A

Who Can Apply?

Nominations will be accepted from the following individuals/groups: - not-for-profit agencies (including sporting clubs) and businesses that are based in the City of Maribyrnong or offer a project here, with a majority of participants based in the municipality - individuals that live in the City of Maribyrnong (Personal Achievement Award); and - individuals that participate in activities in City of Maribyrnong, including volunteering, playing sport or undertaking artistic projects.

Please only nominate someone, a club, business or not for profit organisation who is willing to reveal their personal story to the community. Council’s promotion of M.I.R.A will include: - a presentation on 3 December, International Day for People with a Disability, at the Town Hall - a booklet with local program contact details, and including personal examples and photos of selected award recipients to further inspire others. Not all award winners will be featured.

- promotion in the local newspapers and on the Maribyrnong City Council web site

Maribyrnong City Council Phone: 9688 0200 Fax: 9687 7793 Email: email@maribyrnong.vic.gov.au After Hours/Emergency: 9688 0363 Postal address: PO Box 58, Footscray VIC 3011 Street address: Maribyrnong Council Offices Corner Hyde & Napier Streets Footscray VIC

www.maribyrnong.vic.gov.au

M.I.R.A

How To Nominate?

1.

Complete this nomination form, making sure you indicate the award category for your nomination.

2.

Describe the nominee’s achievements. Your description should address the selection guidelines as detailed in this guide. Your response should be between 400 and 600 words in total. Typed and handwritten nominations will be accepted.

3.

List contact details of two referees that can support the nomination.

4.

Enclose any supporting material such as photographs or brochures (not essential).

5.

Sign the nomination form.

6.

Nominations sent by post must be post-marked no later than 5pm Friday 8 October 2010 to: Maribyrnong City Council MIRA Leisure and Open Space PO Box 58 Footscray Vic 3011

7.

Nominations sent by email must be received no later than 5pm Friday 8 October 2010 to: MIRA@maribyrnong.vic.gov.au

8.

Late nominations will not be considered.

If you have any questions regarding how to nominate, please contact Council Officers, Renee Belsey 9688 0330 or Liz Wright 9688 0313.

Maribyrnong City Council Phone: 9688 0200 Fax: 9687 7793 Email: email@maribyrnong.vic.gov.au After Hours/Emergency: 9688 0363 Postal address: PO Box 58, Footscray VIC 3011 Street address: Maribyrnong Council Offices Corner Hyde & Napier Streets Footscray VIC

www.maribyrnong.vic.gov.au

M.I.R.A

Selection Guidelines The selection panel will use the following criteria to assess nominations. Your nomination should include details of how your nominee meets these criteria.

A.

Describe the nominated person or organisation. Provide some background information about what they have done to become more inclusive, or overcome obstacle to excel in their category, including: What has been achieved; How has this been achieved; and Why have you nominated (yourself/other) for this award.

B.

Highlight what makes their story unique.

Your response should be between 400 and 600 words in total.

Typed and handwritten nominations will be accepted.

Terms and Conditions Please ensure you have read and agree to all the following terms and conditions: 1.

The Nominee meets the ‘Who Can Apply’ section.

2.

The nominee warrants that, to the best of his or her knowledge, all details provided in the nomination are true and correct

3.

Employees of the Maribyrnong City Council and their immediate family and any other people involved with the administration and judging of the 2010 Disability Awards are ineligible to nominate or be nominated for the awards

4.

You may nominate a family member

5.

A referee cannot be a family member of the person nominated

6.

A referee cannot be a family member of the nominator

7.

The selection panel reserves the right not to award a particular category

Maribyrnong City Council Phone: 9688 0200 Fax: 9687 7793 Email: email@maribyrnong.vic.gov.au After Hours/Emergency: 9688 0363 Postal address: PO Box 58, Footscray VIC 3011 Street address: Maribyrnong Council Offices Corner Hyde & Napier Streets Footscray VIC

www.maribyrnong.vic.gov.au

M.I.R.A

8.

The Nominee or Nominator agrees to allow the Maribyrnong City Council to publish the details of the nomination.

9.

Each nominee agrees to be bound by these terms and conditions

Privacy notice Maribyrnong City Council is collecting the information on this form to assess and administer your nomination for the MIRA. Your nomination form cannot be processed without this information.

The Maribyrnong City Council may disclose your personal information if legislation allows or requires this, or where you have given your permission. The Maribyrnong City Council usually gives some or all of this information to the selection committee members. Where selection committee members are external to the Maribyrnong City Council they are required to protect your personal information and not disclose it without your permission.

Proudly supported by

Maribyrnong City Council Phone: 9688 0200 Fax: 9687 7793 Email: email@maribyrnong.vic.gov.au After Hours/Emergency: 9688 0363 Postal address: PO Box 58, Footscray VIC 3011 Street address: Maribyrnong Council Offices Corner Hyde & Napier Streets Footscray VIC

www.maribyrnong.vic.gov.au

M.I.R.A

Nomination Form Nomination category Please indicate which award category your nomination relates to.

o

Inclusive Business Practices

o

Personal Achievement

o

Arts Individual

o

Arts Group

o

Sporting Achievement – Individual

o

Sporting Achievement - Sporting Club

o

Volunteering Award

Details of the Nominee i.e. Individual or Group or Business Name Age (optional) Organisation/club (if applicable) Postal Address

Email

Telephone (during business hours) Maribyrnong City Council Phone: 9688 0200 Fax: 9687 7793 Email: email@maribyrnong.vic.gov.au After Hours/Emergency: 9688 0363 Postal address: PO Box 58, Footscray VIC 3011 Street address: Maribyrnong Council Offices Corner Hyde & Napier Streets Footscray VIC

www.maribyrnong.vic.gov.au

M.I.R.A

Details of Nominator (if different to above) Name Organisation/club (if applicable) Postal Address

Email

Telephone (during business hours) Your relationship to the Nominee

Details of Referee (1) Name Contact Details (either email, work or mobile)

Maribyrnong City Council Phone: 9688 0200 Fax: 9687 7793 Email: email@maribyrnong.vic.gov.au After Hours/Emergency: 9688 0363 Postal address: PO Box 58, Footscray VIC 3011 Street address: Maribyrnong Council Offices Corner Hyde & Napier Streets Footscray VIC

www.maribyrnong.vic.gov.au

M.I.R.A

Details of Referee (2) Name Contact Details (either email, work or mobile)

Maribyrnong City Council Phone: 9688 0200 Fax: 9687 7793 Email: email@maribyrnong.vic.gov.au After Hours/Emergency: 9688 0363 Postal address: PO Box 58, Footscray VIC 3011 Street address: Maribyrnong Council Offices Corner Hyde & Napier Streets Footscray VIC

www.maribyrnong.vic.gov.au

M.I.R.A

Nominee’s achievements and contribution to the community – WHAT, HOW & WHY

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Maribyrnong City Council Phone: 9688 0200 Fax: 9687 7793 Email: email@maribyrnong.vic.gov.au After Hours/Emergency: 9688 0363 Postal address: PO Box 58, Footscray VIC 3011 Street address: Maribyrnong Council Offices Corner Hyde & Napier Streets Footscray VIC

www.maribyrnong.vic.gov.au

M.I.R.A

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Maribyrnong City Council Phone: 9688 0200 Fax: 9687 7793 Email: email@maribyrnong.vic.gov.au After Hours/Emergency: 9688 0363 Postal address: PO Box 58, Footscray VIC 3011 Street address: Maribyrnong Council Offices Corner Hyde & Napier Streets Footscray VIC

www.maribyrnong.vic.gov.au

M.I.R.A

Signatures I certify that the information contained in this information is true and correct.

Signature of nominator

.........................................................................................................

Signature of nominee

…………………………………………………………………………… (if different from above) Signature of parent/teacher/ guardian

.......................................................................................................... (if nominator is under 18 years of age)

Maribyrnong City Council Phone: 9688 0200 Fax: 9687 7793 Email: email@maribyrnong.vic.gov.au After Hours/Emergency: 9688 0363 Postal address: PO Box 58, Footscray VIC 3011 Street address: Maribyrnong Council Offices Corner Hyde & Napier Streets Footscray VIC

www.maribyrnong.vic.gov.au

M.I.R.A

Photo Release Form I……………………..…of ………………………………..… (insert full name) (insert full address) authorise Maribyrnong City Council to photograph me or my child/ward in a lifestyle situation at various locations. I am aware the images will be used for the sole purpose of producing advertising/promotional material for Maribyrnong City Council.

My contact details are: Telephone:…………………..………………………….…………

Email:…………………………..………………………………..…

Signature:……………………………..……………………………

Date:……..…………………………..…………………………..… (of guardian/parent if person is under 18 years of age) CouncilRepresentative:……………………………………………

Signature:……………………..……..…………….……………..…

Note: Council representative should write their name on the form before giving it out so it is returned to the correct officer.

Privacy Statement Council collects your personal contact details in order to effectively manage its photographic library. If you have any queries or wish to gain access to your information, please contact Council’s Communications Team on 9688 0247.

Staff use only Please ensure any photographs kept for Council’s collection in conjunction with this release form be photocopied / printed out, attached to this form and given to the Communications Team. This will ensure that if this person would like their photographs removed from Council’s collection at any stage, it will be easier to identify the photographs.

Maribyrnong City Council Phone: 9688 0200 Fax: 9687 7793 Email: email@maribyrnong.vic.gov.au After Hours/Emergency: 9688 0363 Postal address: PO Box 58, Footscray VIC 3011 Street address: Maribyrnong Council Offices Corner Hyde & Napier Streets Footscray VIC

www.maribyrnong.vic.gov.au