District No.

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

Name (if known) or description

......... Applicant

of ..........

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

of .........

UPON APPLICATION made to this Court to-day by the above-named applicant under section 12 (4) of the above-mentioned Act for an emergency care order in respect of the child *named *described above, who appears to the Court to be aged ..... years, having been born *(as far as has been ascertained) on the ... day of ...... 19...

and who resides at ........

*(in the said court district) and who was delivered up to the custody of the applicant health board on the ... day of ..... 19... by a member of the Garda Síochána under section 12 (3) of the Act and who is now in the custody of the applicant in the said court district,

THE COURT *(being satisfied that notice of the application was duly served upon the respondent,)

having heard the evidence tendered herein,

being of opinion that there is reasonable cause to believe that there is likely to be an immediate and serious risk to the health/welfare of the child if the child is removed from the place where he/she is for the time being, and

being satisfied that the welfare of the child requires that this order be made,

HEREBY ORDERS that the child *named *described above be placed under the care of the applicant health board for the period of ........ days (being a period not exceeding eight days) from the date hereof;

*(AND DIRECTS under section 13 (7) (a) of the Act as follows:—

).

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

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

Judge of the Children Court

*(for the said district).

* Delete words inapplicable