District No.

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

.......... Applicant

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

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

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

WHEREAS on the application of the above-named Health Board under section ...... of the above-mentioned Act, the Court on the ... day of ..... 19.... made a supervision order authorising that board to have the above-named child who resides at ......... in the area of the board and in the said court district, visited on such periodic occasions as the board may consider necessary in order to satisfy itself as to the welfare of the child and to give to *(his/her parents) *(the person acting in loco parentis) any necessary advice as to the care of the child

AND WHEREAS the above-named applicant, being a *(parent of the child) *(person acting in loco parentis), is dissatisfied with the manner in which the health board is exercising its authority to have the child visited in accordance with section 19 of the Act,

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 directions under section 19 (3) of the Act as to the manner in which the child is to be visited.

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

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

Applicant

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

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

the above-named health board

* Delete words inapplicable