Volunteer Recognition Form

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Your Details

Enter the details of the person nominating the Volunteer.

Your Name*

Your Email Address*

Your Phone Number*

Relationship to Volunteer*

Volunteer Details

Enter the details of the nominated Volunteer.

Volunteer's name*

Volunteer's phone number*

Volunteer's email address*

Volunteering Details

Enter the details of the nominated person's volunteer history.

Volunteer Organisations*

Volunteer Role(s)*

Years of Service*

5 Years10 Years

Recognition Statement*

References

Enter details of at least 1 reference for the Volunteer.

Please List a Reference*

Consent

I confirm that, to the best of my knowledge, the information provided is accurate.

I understand the nominee may be publicly recognised at the event.

I give permission for the Shire of Wyndham-East Kimberley to use the nominee’s name and image in media and promotional material (subject to nominee approval).

Signiture*

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