Juiced TV's Super Hero Awards
Nomination Form
YOUR DETAILS
Parent/Guardian First Name
*
(required)
Parent/Guardian Last Name
*
(required)
Child's name
*
(required)
Child's Date of Birth
*
(required)
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Approximate date of hospital admission
*
(required)
Mobile Phone
*
(required)
Address
Postcode
*
(required)
Email
*
(required)
YOUR SUPER HERO NOMINEE'S DETAILS
Nominee First Name
*
(required)
Nominee Surname
*
(required)
Nominee Role
*
(required)
Nominee Department / Location
*
(required)
In 150 words or less, tell us why you are nominating this individual for Juiced TV's Super Hero Award?
*
(required)
Please tell us a little bit about the relationship between the child and the nominee - including any anecdotes, common interests, or noteable details.
By submitting your nomination, you agree to be contacted by Juiced TV, QSuper or Children's Health Queensland in relation
to Juiced TV's Super Hero Award Program only.
I agree to the terms and conditions above
*
(required)
Yes
I acknowledge that this incredible story may be shared with external media.
*
(required)
I acknowledge and agree
I require more information before agreeing
Juiced TV's Super Hero Awards are proudly supported by
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