District No.

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

Name (if known) or description

................ Applicant

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

.......... Respondent

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

WHEREAS on the application of the ............ Health Board, made under section *12 (4) *13 (1) of the above-mentioned Act, this Court on the ... day of ..... 19...., made an emergency care order placing the child *named *described above under the care of that board for a period of ...... days,

AND WHEREAS the Court *(on the ... day of ..... 19.... on the application of , of .............) gave directions in relation to the said child under section 13 (7) (a) of the Act,

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 13 (7) (b) of the Act to have the direction with respect to:—

*discharged

*varied as follows:—

on the grounds that—

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

Signed ................
Applicant

To .........

of ..........

To ........

of .......

the above-named respondent(s)

* Delete words inapplicable