District No.

In the matter of .......... a child

Name (if known) or description

......... Applicant

of ........

........... Respondent

of ...........

WHEREAS the child referred to above, who *is *appears to be aged .... years, having been born *(so far as has been ascertained) on the ... day of .... 19 ..... *resides

*has been found at ..........

in the area of the applicant health board and in said court district,

AND WHEREAS the applicant believes that—

*the child has been or is being assaulted, ill-treated, neglected, sexually abused,

*the child's health, development or welfare has been or is being avoidably impaired or neglected,

*the child's health, development or welfare is likely to be avoidably impaired or neglected.

AND WHEREAS an application for a care order in respect of the child has been or is about to be made by the applicant,

TAKE NOTICE that the applicant will apply at the sitting of the District Court to be held at ...... on the .... day of ...... 19... at ........ a.m./p.m. for an interim care order under section 17 (1) of the above-mentioned Act *placing *maintaining the child in the care of the applicant health board pending the determination of the application for the care order.

Dated this .... day of ....... 19....

Signed ...............

Solicitor for Applicant

To ...............

of ..................

the above-named respondent.

* Delete words inapplicable