District No.

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

......... Applicant

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

.......... Respondent

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

UPON APPLICATION made to this Court to-day by the above-named applicant under section 17 (1) of the above-mentioned Act for an interim care order in respect of the above named child, who appears to the Court 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 an application for a care order in respect of the child has been/is about to be made,

that there is reasonable cause to believe 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 be avoidably impaired/neglected, and that it is necessary for the protection of the child's health/welfare that he/she be placed/maintained in the care of the applicant health board pending the determination of the application for the care order,

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

HEREBY ORDERS that the above-named child ............ be *placed *maintained in the care of the applicant health board

*[for the period of ..... days (being a period not exceeding eight days) from the date hereof

*the date upon which the child is delivered into the custody of the board]

*[for the period of ..... days (being a period exceeding eight days and the applicant and respondent consenting to such period) from *the date hereof *the date upon which the child is delivered into the custody of that board]

*(AND FURTHER ORDERS that the directions already given under section 13 (7) of the Act in respect of the said child shall remain in force *(subject to the following variation(s))—

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

]

)

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

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

Judge of the Children Court

* Delete words inapplicable