.............. Applicant

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

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

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

WHEREAS 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..., resides at ............ in the area of the applicant board and in the said court district,

AND WHEREAS the applicant believes that—

*(the child has been/is being assaulted/ill-treated/neglected/sexually abused,)

(or)

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

(or)

*(the child's health/development/welfare is likely to be avoidably impaired/neglected,) and it is desirable that the child be visited periodically by or on behalf of the health board,

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 a supervision order under section 19 (1) of the Act with respect to the said child.

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

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

Solicitor for Applicant

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

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

the above-named respondent

* Delete words inapplicable