District No.

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

........ Applicant

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

......... Respondent

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

WHEREAS on the application of .......... Health Board, made under section 17 (1) of the above-mentioned Act, this Court on the ... day of ....... 19.... made an interim care order *placing *maintaining the above-named child in the care of that health board for the period of ..... days,

TAKE NOTICE that the above-named 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 an extension, under section 17 (2) of the Act, of the period of the said interim care order for a further period of ....... days.

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

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

Solicitor for Applicant

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

of .........

the above-named respondent.

* Delete words inapplicable