District No.

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

Name (if known) or description

........ Applicant

of .........

........ Respondent

of ..........

WHEREAS application has been made to this Court by the ....... Health Board under section 18 (1) of the above-mentioned Act, for a care order with respect to the above-mentioned child who *resides *has been found at ....... area of the board and in the said court district,

AND WHEREAS the said application has not yet been determined by the Court,

TAKE NOTICE that the applicant herein will make application at the sitting of the

District Court to be held at ..... on the ... day of .... 19... at .... a.m./p.m. for the Court's directions under section 18 (6) of the Act as to the care and custody of the child pending such determination.

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

Signed ........

Applicant

To ......

of .........

the above-named respondent.

* Delete words inapplicable