Please ensure all questions are completed, including the supporting statement before submitting your nomination. If you have any enquiries please contact communications@world.physio
Details of individual being nominated

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* 1. First name

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* 2. Last name

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* 3. Member of (World Physiotherapy member organisation)

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* 4. Is the individual aware of the nomination?

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* 5. Has the individual consented to the nomination? (consent is optional)

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* 6. Email

Details of nominator

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* 7. Name of organisation

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* 8. Name of person nominating

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* 9. Position in the organisation

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* 10. Email

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* 11. Has the nomination been agreed by the board/ executive committee or other appropriate body in your World Physiotherapy member organisation, region or specialty group?

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* 12. Date agreed

Date

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* 13. Area(s) of contribution (tick all applicable)

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* 14. Period of major contribution

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* 15. Level at which contribution had the greatest impact

Diversity, equity and inclusion

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* 16. Does this nomination reflect the diversity of the global physiotherapy profession? Has the nominee contributed to improving equity, access, or inclusion?

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* 17. If yes or partially, please explain

Supporting statement

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* 18. In support of the nomination please submit a brief description (max 3000 characters) of the nominee's noteworthy contribution to, and impact on the physiotherapy profession. Nominations must focus on demonstrable impact and influence, rather than length of service or seniority alone.

Declaration

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* 19. I confirm that the information provided is accurate and that the nominee meets the criteria outlined in the terms of reference.

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* 20. Please confirm you understand that the information supplied on this form will be stored on World Physiotherapy systems.  You have the right to access, amend and oppose any use of this personal data by writing to World Physiotherapy at info@world.physio.

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