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Injury Report Form

Please fill out the following form
to report important information to management.

Your name

Date of incident * required

This report is a; *

Hazard / Maintenance required

Incident / Injury

Breakdown

Date this occured * required

Time

If this is a Hazard, Maintenance or Breakdown report

Full Name (injured)

Phone

Full Name (witness)

Phone

Address

Date of birth

Is the injured person a;

Where did the incident occur

Was first aid required

Statement of what happened

Is follow up required

Your Signature

Phone Us

03 5792 1003

Email Us

manager@theprinceseymour.com.au

Find Us

48 Emily Street, Seymour VIC 3660

Open for lunch and dinner, or as a destination venue
to celebrate special occasions, book a private function or fundraiser events.

Contact us to discuss your perfect wedding celebration with us.

Facilities.
Public Bar | Kids playroom | High Chairs | Baby change table |
Pool Table | Indoor dining | Outdoor dining | Fire Pit

the

PRINCE

of Wales

Seymour | Places to dine

Seymour | Places for lunch

Seymour | Places to drink

Seymour | Sports Bar

Seymour | Function Venue

Seymour | Wedding Venue

Seymour | Christmas Parties

Seymour | Group bookings

Seymour | Father's Day

Seymour | Grand Final Day

Seymour | Australia Day
Seymour | Valentines Day

© 2020 Seymour Prince Pty. Ltd.

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