District No.

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

......... Applicant

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

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

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

WHEREAS ON APPLICATION by the ....... Health Board, made under section 17 (1) of the above-mentioned Act, the Court on the ........ day of ... I9... made an interim care order *placing *maintaining the above-named child in the care of that health board for the period of .... days,

NOW, THE COURT on the application of the applicant herein for an extension of the period of the said interim care order, being satisfied that notice of the application was duly served, having heard the evidence tendered herein,

being satisfied—

that grounds for the making of an interim care order continue to exist with respect to the child, and that the welfare of the child so requires,

HEREBY GRANTS an extension of the period of the interim care order in respect of the said child

*[for the further period of ...... days (being a period not exceeding Bights days) from the ... day of ....... 19....]

*[for the further period of ...... days (being a period exceeding eight days and the applicant and respondent consenting to such period) from the ... day of ....... 19.....]

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

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

Judge of the Children Court

* Delete words inapplicable