2017 William Wallace nomination form
Details of the young person being nominated for a William Wallace Award:
Surname:
First name(s):
Preferred name:
Date of birth:
Ethnicity:
Legal status:
Gender:
Street address:
Suburb:
Town/city:
Daytime contact number:
Postcode:
After hours contact number:
Caregiver(s) name(s):
Name of young person’s social worker:
Details of the person nominating a young person for a William Wallace Award:
Organisation (if relevant):
Surname:
First name(s):
Relationship to the young person:
Daytime contact number:
After hours contact number:
PO Box or street address:
Suburb:
Town/city:
Postcode:
Name of young person’s social worker:
Ministry for Vulnerable Children, Oranga Tamariki site address: PO Box
Suburb:
City:
Region:
Daytime contact number:
Please select the award category that you are nominating the young person for (you may tick more than one
box)
William Wallace Award categories:
Tertiary Study
Vocational Programme
Leadership Programme
GFS Scholarship
Outward Bound Scholarship
(Go on to further study after school)
(To help a young person train for a career or buy equipment)
(To help a young person develop their potential through a course)
(For a young woman in the greater Wellington region)
(To help a young person complete an Outward Bound course)
About the young person
What will they use the scholarship money for? (E.g. contribution towards fees for Outward Bound
course, formal tertiary or vocational study – please list, purchasing equipment?)
How has the young person been involved in making their nomination? (E.g. gathering of references,
photos, certificate copies)
Background of the young person: (Brief family history and summary of involvement with Ministry for
Vulnerable Children, Oranga Tamariki, and their current living arrangements).
(There is no word limit, for this section keep their family and social services background brief, but please
tell us more about their current living situation – i.e caregivers and how long they’ve been with them, or
are they transitioning to independence, with an NGO?)
Why do you think this young person should receive a William Wallace Award? (What are their
strengths and achievements, what are their hopes and dreams for the future - career aspirations? Let us
know about any academic levels they have achieved – for example NCEA).
(There is no word limit, please include as much information as you can to tell us about this amazing young
person.)
Tell us about the key support networks for the young person: (These could include family – natural
and foster, friends, Lawyer, Counsellor, teachers and volunteers, people in the community).
If successful, does the young person wish to be identified in the media? (E.g. in a regional newspaper
or magazine as part of a good news story). If the young person wishes to remain anonymous, it will not
affect their application).
Yes
No
If successful, does the young person agree to be identified in Care Matters (our newsletter for
caregivers)?
Yes
No
If the young person is successful, do they wish to attend the award ceremony? (We will pay travel
costs for the winner and one support person to attend the ceremony held in Wellington).
Yes
No
Is the young person available to take up the award next year? (It is recommended that the young
person is able to claim the award money in the year following their award ceremony).
Yes
No
Please list any supporting documentation that is included as part of this nomination (These can
include things like reference letters from their school, certificates of achievement, any photo, stories,
artwork by the young person)

Site Manager approval (for Ministry for Vulnerable Children, Oranga Tamariki applications only)
I Site Manager's full name confirm that I have read this nomination and have checked that the young
person is eligible for this award, and I formally approve the nomination to be submitted for a William
Wallace Award.
Signed:
Date:
Site Manager’s approval (for printed
nominations)
Approved:
Date:
Site Manager’s approval (for email
nominations)
Please print and return this completed nomination form by Friday 4 August 2017 to:
William Wallace Awards
Communications National Office
Ministry for Vulnerable Children, Oranga Tamariki
Private Bag 1556
Wellington 6140
Or, you can email your nomination along with scanned copies of any supporting documentation to:
[email protected].
Thank you for nominating a special young
person you know.