Awards nomination form - Leadership through Lived Experience Award

Recognising an individual with lived experience of mental ill-health, mental illness, or a carer of someone with lived experience, who has made outstanding contributions to advocacy and social change benefitting people with lived experiences. This can relate to a specific program the person has initiated/coordinated, or a dedication to lifelong work in this area.

Nominator's details

Nominator's Name*

Position

Phone*

Email*

Nominee details

Please provide contact details of the program/project or individual you are nominating

Program/Project name

If relevant to this individual's nomination, please include the name of the program or project they have worked on

Organisation/group/company name

If the individual is associated with a specific organisation, please include the organisation name

Nominee Name*

Nominee contact email*

Nominee contact phone*

Street address*

Address 2

Suburb*

State*

Postcode*

Nomination criteria

To submit a nomination in this category, address the following criteria to support this nomination (the supporting information cannot exceed 1500 words).

1. Provide a brief account of the individual that is being nominated, and the work they’ve done.*

Include the aims of any project or program they’ve run

2. How has their work contributed to advocacy and social change for people with lived experience of mental ill-health?*

3. What are some of the longer term impacts the individual has had on the lives of people with lived experiences of mental health issues?*

Please include links to any feedback, media, or other supporting information

Please attach any supporting documents if you have them

Drag and drop files here or

How did you hear about the Mental Health Matters Awards*

Select or enter value

Other:

Disclaimer

The Mental Health Matters Awards are judged solely on the content provided to WayAhead - Mental Health Association NSW (WayAhead) with each nomination and with minimal additional checking performed by the selection panel. WayAhead relies on the information provided by the nominees and their declaration as to its accuracy and completeness and the inclusion of nominees in the list of nominees and the issue of an Award or commendation to a recipient ("Award recipient") is not an endorsement or recommendation by WayAhead of the Award recipient's products or services. Users of products or services supplied by nominees or Award recipients should satisfy themselves that they are appropriate, of suitable quality and adequate for a user's particular needs.WayAhead gives no warranties and makes no representations as to the suitability or fitness of particular products or services for the particular uses or purposes of any user and accepts no responsibility for any loss, damage or claim arising in any way from the use of any such products or services.

Declaration by nominator

I declare that: - All the information submitted in this nomination form is true and accurate in all material respects and is not misleading or incomplete in any material way. - The information submitted complies with the criteria of the Mental Health Matters Awards and the nominee is eligible to be nominated. - There are no facts or circumstances which would, if disclosed, disqualify the nominee or, if any Award or commendation is made to the nominee, would result in that Award of commendation being withdrawn. - The products and services provided by the nominee comply with all applicable laws and are suitable and fit for the purposes for which they are provided and there are no unresolved significant complaints or claims relating to the nominee's products and services. - There are no facts or circumstances relating to the nominee which, if any Award or commendation is made to the nominee, may harm the reputation of WayAhead. - I am authorised to make this declaration on behalf of the nominee

I have read the above and agree*

Date

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