District No.

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

........ Applicant

of .........

.......... Respondent

of .........

WHEREAS ON APPLICATION by the above-named health board under section 18 (1) of the above-mentioned Act for an order with respect to the above-named child who *is *appears to be aged ..... years, having been born *(so far as has been ascertained) on the ... day of ....., 19.... and who *resides *has been found at ......... in the area of the board and in the said court district, THE COURT HAS to-day made a care order committing the child to the care of that health board for the period from the ... day of ..... 19.... to the ... day of ......., 19....

NOW, THE COURT being satisfied that the above-named respondent(s) *is *are the parent(s) of the child, and

having regard to the means of the said parent(s),

HEREBY ORDERS under section 18 (7) of the Act that you, ........... parent(s) of the child .......... do contribute to the ........... health board towards the cost of maintaining the child the weekly sum of £.... for the whole of the period during which that care order is in operation or until further order of the court herein - the first of such weekly sums to be paid on the ... day of ..... 19....

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

Signed ..........

Judge of the Children Court

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

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

Parent(s) of the above-named child.

* Delete words inapplicable