2016 PIERRE DE COUBERTIN AWARD SSANOMINATION FORM
SELECTION CRITERIA AND GUIDELINES
The State Sporting Association must be on the current Olympic program and a member of the Victorian Olympic Council. At some stage throughout their sporting career, the selected athlete must:
Be a registered member of the SSA
Be enrolled in years 10, 11 or 12 and not have received the Award on a previous occasion.
Have participated actively in the SSAs competition program with a consistently positive attitude
Be actively involved in school or community sport, including but not limited to competing, volunteering, coaching, officiating, administration or club development
Demonstrate the attributes consistent with the fundamental aims of the Olympic movement, and
Submit a digital media, literacy or artistic piece that depicts an appreciation of Olympism in response to this year’s theme “How has sport change YOUR life or YOUR community?”A digital media, literary or artistic piece related to the theme must accompany the nomination form otherwise it will be deemed invalid. All pieces submitted remain the property of the VOC and where appropriate may be used in official publications. Please note:
- Literary pieces must be a MAXIMUM of 300 words (typed) in length.
- Artistic pieces must be within the confines of 64x45cm or equivalent in 3D. An artistic piece could refer to, but is not limited to, a painting, collage or framed piece.
- Digital Media pieces refer to audio, video, and photo content that has been encoded (digitally compressed) i.e. converting audio and video input into a digital media file such as a Windows Media file. A digital media piece could refer to, but is not limited to, a musical recording, videography or PowerPoint presentation which is a MAXIMUM of 3minutes.
OLYMPIC ACADEMY AND AWARDS CEREMONY PROGRAM OVERVIEW & NOMINATION
10.30am Registration
11am-4pm Olympic Academy (Limited places available; lunch will be provided for students)
5pm-7pm Pierre de Coubertin Awards Ceremony
The program is free of charge and students will be provided with refreshments throughout the day. Please complete the details below and return via email or mail to the Victorian Olympic Council by May 12th, 2016. Once the forms are returned, more information about the ceremony will be sent.
State Sporting Association:
SSA Contact First Name:SSA Contact Surname:
SSA Contact Email Address:
SSA Contact Phone Number:
Athlete First Name: Athlete Surname:
Athlete School Name:
Athlete School Level:Athlete Sport Level:
Athlete Street Address:
Athlete Suburb:Athlete State:Athlete Postcode:
Athlete Contact Number:
Athlete Email Address:
SPORTING HIGHLIGHTS
Briefly describe the student’s attitude and motivation through their participation in physical education and sport i.eProvide an example of when they displayed good sportsmanship and/or explain the student’s involvement in the above criteria (200 words max). This citation will be presented in a booklet to each student.Example: Sue is an outstanding role model in sport and physical education.Her positive attitude is quite contagious. She leads by example and has sustained an excellent level of participation in a range of sports. Her level of determination is second to none! Sue maintains exemplary conduct on the sporting field and embodies the qualities of fair play, respect and sportsmanship.
RED DUST – HEALTHY LIVING PROGRAM
Please tick the box if you are interested in applying for the Red Dust Healthy Living Program.
2016 OLYMPIC ACADEMY REGISTRATION FORM – TWO ADDITIONAL REPRESENTATIVES
In addition to nominating you Pierre de Coubertin award recipient, all SSAs are invited to nominate two additional participants to represent your sport on the day. In order to attend the program, please complete the registration form/s below and return to the Victorian Olympic Council by 5pm Thursday May 12.
PROGRAM OVERVIEW
Thursday June 23, 2016 – Melbourne Cricket Ground (MCG)
10.30am Registration
11am-4pm Olympic Academy (Limited places available; lunch will be provided for students)
5pm-7pm Pierre de Coubertin Awards Ceremony
The program is free of charge and students will be provided with refreshments throughout the day
ATTENDANCE (PARTICIPANT 1 OF 2)
State Sporting Association (SSA):
SSA Contact Name:
Athlete’s Name:
Athlete’s Email Address:
Athlete’sSchool Name:
□I will be attending BOTH the awards ceremony and Olympic Academy on Thursday June 23 at the MCG.
□I will ONLY be attending the awards ceremony on Thursday June 23at the MCG from 5pm – 7pm.
Parent/Guardian Name:
Parent/Guardian Mobile Number:
Parent/Guardian Email Address:
For security purposes we require parents to collect students from MCG at the conclusion of the program at 7pm. Please complete the details below if you give permission for the student to leave the Academy without being signed out by a parent/guardian. Please note the program and event details will be forwarded once the registration form is returned.
I, ______give permission for ______to leave the program at the MCG on June 23 (at _____ pm*) at the conclusion (approx. 7pm).
Parent/Guardian Signature: Date:
*please specify a time should the student require to leave before the conclusion of the Olympic Academy at 4pm.
PERMISSION FOR PHOTOGRAPHY-to be completed by a parent/guardian
During the Award Ceremony and Olympic Academy, photographs of the students may be taken whilst receiving their Award and throughout the day while participating in activities. These photos may be used for promotion of the awards and Academy by the Victorian Olympic Council and the Department of Education and Training via our newsletters, websites and reports. For this to occur, the permission of a parent or guardian is required.
I, ______give permission for the photo of ______to be taken and reproduced for promotional purposes by the Victorian Olympic Council and Department of Education and Training in their publications and online.
Parent/Guardian Signature: Date:
Parent/Guardian Mobile Number:
PLEASE POST OR EMAIL THIS FORM BEFORE 5PM ON THURSDAY MAY 12, 2016. EMAIL:
2016 OLYMPIC ACADEMY REGISTRATION FORM – TWO ADDITIONAL REPRESENTATIVES
In addition to nominating you Pierre de Coubertin award recipient, all SSAs are invited to nominate two additional participants to represent your sport on the day. In order to attend the program, please complete the registration form/s below and return to the Victorian Olympic Council by 5pm Thursday May 12.
PROGRAM OVERVIEW
Thursday June 23, 2016 – Melbourne Cricket Ground (MCG)
10.30am Registration
11am-4pm Olympic Academy (Limited places available; lunch will be provided for students)
5pm-7pm Pierre de Coubertin Awards Ceremony
The program is free of charge and students will be provided with refreshments throughout the day
ATTENDANCE (PARTICIPANT 2 OF 2)
State Sporting Association (SSA):
SSA Contact Name:
Athlete’s Name:
Athlete’s Email Address:
Athlete’s School Name:
□I will be attending BOTH the awards ceremony and Olympic Academy on Thursday June 23 at the MCG.
□I will ONLY be attending the awards ceremony on Thursday June 23at the MCG from 5pm – 7pm.
Parent/Guardian Name:
Parent/Guardian Mobile Number:
Parent/Guardian Email Address:
For security purposes we require parents to collect students from MCG at the conclusion of the program at 7pm. Please complete the details below if you give permission for the student to leave the Academy without being signed out by a parent/guardian. Please note the program and event details will be forwarded once the registration form is returned.
I, ______give permission for ______to leave the program at the MCG on June 23 (at _____ pm*) at the conclusion (approx. 7pm).
Parent/Guardian Signature: Date:
*please specify a time should the student require to leave before the conclusion of the Olympic Academy at 4pm.
PERMISSION FOR PHOTOGRAPHY-to be completed by a parent/guardian
During the Award Ceremony and Olympic Academy, photographs of the students may be taken whilst receiving their Award and throughout the day while participating in activities. These photos may be used for promotion of the awards and Academy by the Victorian Olympic Council and the Department of Education and Training via our newsletters, websites and reports. For this to occur, the permission of a parent or guardian is required.
I, ______give permission for the photo of ______to be taken and reproduced for promotional purposes by the Victorian Olympic Council and Department of Education and Training in their publications and online.
Parent/Guardian Signature: Date:
Parent/Guardian Mobile Number:
PLEASE POST OR EMAIL THIS FORM BEFORE 5PM ON THURSDAY MAY 12, 2016. EMAIL:
PIERRE DE COUBERTIN AWARD NOMINATION AND RED DUST APPLICATION FORM