Queensland Moderator's Community Service Medal 2022 nomination form

Nominee details

These questions are about the person you are nominating. Please submit a separate form for each nomination.

Please note that nominees must not be currently employed by the Uniting Church or one of its agencies (e.g. UnitingCare, Wesley Mission)

Question Title

* 1. Nominee contact information

Name

Address

Address 2

City/Town

State

Postal Code

Email Address

Phone Number

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* 2. Which community service groups has the nominee undertaken volunteer work in?

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* 3. Please describe the ways in which the nominee’s volunteer work truly reflects UnitingCare Queensland’s mission statement:

To improve the health and wellbeing of individuals, families and communities as we: Reach out to people in need; Speak out for fairness and justice; Care with compassion, innovation and wisdom.

In your answer talk about the nature, breadth, innovation and impact of the person’s volunteering service.

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* 4. How many years has the nominee undertaken volunteer work for?

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* 5. Please add any other significant information to demonstrate why your nominee deserves to be recognised.

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* 6. Is the nominee currently employed by the Uniting Church or one of its agencies? (e.g. UnitingCare, Wesley Mission)

Yes

No

I'm not sure

Nominator details

These questions are about you, the person making the nomination.

Question Title

* 7. Nominator contact information

Name

Address

Address 2

City/Town

State

Postal Code

Email Address

Phone Number

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* 8. Are you a member of a congregation or church agency? Please provide details.

Thank you.