District No.

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

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

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

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

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

WHEREAS ON APPLICATION by the above-named Health Board under section ....... of the above-mentioned Act, THE COURT on the ... day of ......... 19.... MADE A SUPERVISION ORDER in respect of the above-named child who resides at ........... in the area of the board and in the said court district,

NOW, THE COURT on the application of the above-named applicant, being a *(parent of the child) *(person acting in loco parentis), for directions under section 19 (3) of the Act, the said applicant being dissatisfied with the manner in which the board is exercising its authority to have the child visited in accordance with section 19 of the Act,

being satisfied that notice of the application was duly served,

having heard the evidence tendered, and

being satisfied that the welfare of the child so requires,

HEREBY DIRECTS under the said section 19 (3) as follows:—

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

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

Judge of the Children Court