District No.

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

......... Applicant

of .........

.......... Respondent

of .........

UPON APPLICATION made to this Court today by the above-named applicant under section 18 (1) of the above-mentioned Act for a care order with respect of the above named child, who 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 applicant health board and in the said court district,

THE COURT being satisfied that notice of the application was duly served, having heard the evidence tendered herein, and being satisfied that—

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

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

*the child's health/development/welfare is likely to he avoidably impaired/neglected, the child requires care/protection which he/she is unlikely to receive unless the Court makes an order under the said section 18 (1), and

that the welfare of the child so requires,

HEREBY ORDERS that the said child ........... be committed to the care of the applicant health board—

*(for so long as he/she remains a child, that is to say, until the ... day of ..... 19..). *(for the period from the ... day of ..... 19... until the ... day of ..... 19..).

*(for the period from the date upon which the child is delivered into the custody of the board until the ... day of ...... 19...).

*(AND DIRECTS as follows:—

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

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

Judge of the Children Court

* Delete words inapplicable