District No.

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

........ Applicant

of .........

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

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

UPON APPLICATION by the above-named applicant made to the Court to-day for an order under section 37 (2) (a) of the above-mentioned Act in respect of the above-named child, who is in the care of the above-named health board at ....... in the said court district, the said applicant being dissatisfied with the arrangements made by the board regarding access to the child,

THE COURT being satisfied that notice of the application was duly served,

having heard the evidence tendered and

being satisfied that the welfare of the child so requires,

HEREBY ORDERS as follows:—

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

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

Judge of the Children Court