District No.

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

........ Applicant

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

........ Respondent

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

WHEREAS the above-named child is in the care of the ...... Health Board at ....... in the said court district,

AND WHEREAS on the application of ........ of .......... the Court on the ... day of ..... 19..... made an order under section 37 (2) (a) of the above-mentioned Act regarding access to the child as follows:—

TAKE NOTICE that the applicant herein will apply at the sitting of the District Court to be held at ......... on the ... day of ..... 19.... at ... a.m./p.m., under section 37 (2) of the Act to have the said Order *discharged/*varied as follows:—

on the grounds that:—

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

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

Applicant

To .......

of .........

* Delete words inapplicable