Bravery Awards Nomination

WA Bravery Awards Nomination

The Royal Life Saving WA Bravery Awards are designed to recognise and acknowledge the efforts and actions of people in the WA community who have performed a rescue and/or resuscitation, applying their knowledge to save another’s life.

To nominate someone for a Bravery Award, please fill out the form below.

Nomination Category *

Section 1: Details of the Nominee

Please complete as many details as possible. Space is provided below to nominate up to four individuals for the same incident. Please contact Royal Life Saving if you wish to nominate more people.

Number of Nominees *

Nominee 1

Given Name *

Surname *

Date of Birth

Address

Street address

City

State

Postcode

Home Phone

Business Phone

Mobile *

Email *

Nominee 2

Given Name *

Surname *

Date of Birth

Address

Street address

City

State

Postcode

Business Phone

Home Phone

Mobile *

Email *

Nominee 3

Given Name *

Surname *

Date of Birth

Address

Street address

City

State

Postcode

Home Phone

Business Phone

Mobile *

Email *

Nominee 4

Given Name *

Surname *

Date of Birth

Address

Street address

City

State

Postcode

Home Phone

Business Phone

Mobile *

Email *

Section 2: Details of the incident

Please provide as much information as possible to assist the Committee in making a decision.

Date of the Incident *

Location of Incident *Please include information such as landmarks and any other location information mentioned in your description of the incident.

Please describe the circumstances of the incident *Include a description of environmental conditions (if relevant) and who was injured or required rescuing.

Please provide a detailed description of the actions taken by the nominee in relation to the situation *Include a description of environmental conditions (if relevant) and who was injured or required rescuing.

Please indicate the reasons why you think the nominee’s actions should be considered for a Bravery Award *

Outcome of the scenario (if known)

Do the nominees have any first aid qualifications? *This may include but is not limited to Resuscitation, First Aid, Bronze Medallion, Pool Lifeguard etc.

Please specifiy what qualification and where they completed the course (if known)

Please provide details of any other people or rescue services involved with the incident that you have not previously mentioned *

Section 3: Details of witness (if applicable)

Please inclue the details of any witnesses who may be able to verify the information provided above or supply additional information. If not applicable, please leave blank.

Given Name

Surname

Date of Birth

Address

Street address

City

State

Postcode

Home Phone

Business Phone

Mobile

Section 4: Details of nominee’s parent/guardian (if nominee is under the age of 18)

Given Name

Surname

Date of Birth

Address

Street address

City

State

Postcode

Home Phone

Business Phone

Mobile

Section 5: Nominator's Details

Given Name *

Surname *

Date of Birth

Address

Street address

City

State

Postcode

Home Phone

Business Phone

Mobile *

Email *

Declaration

I wish the nominate the above-named person for a Royal Life Saving Bravery Award for the actions specified above.

By checking this box, I declare that the information I have supplied in this nomination is accurate and correct to the best of my knowledge based upon my observations of the described incident. *

Supporting Documents

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