S.I. No. 104/1953 - Adoption Act, 1952, Rules, 1953.

S.I. No. 104 of 1953.

ADOPTION ACT, 1952, RULES, 1953.

An Bord Uchtála, with the consent of the Minister for Justice and in exercise of the powers conferred on it by the Adoption Act, 1952 (No. 25 of 1952), hereby makes the following rules:—

1. These rules may be cited as the Adoption Act, 1952 , Rules, 1953.

2. In these rules—

"the Act" means the Adoption Act, 1952 (No. 25 of 1952);

"the Board" means An Bord Uchtála;

"the Chairman" means the Chairman of the Board;

"the Registrar" means the Registrar of the Board.

3. Each of the forms set out in the Schedule shall be used in the case and manner indicated by the form.

4. The Board may require an applicant for an adoption order to submit medical evidence of the state of his health.

5. The Board may require any statement in a prescribed form to be verified by oral or other evidence.

6. The Registrar shall give to every applicant for an adoption order at least ten days' notice in writing of the date, hour and place of hearing of the application.

Form 1.

APPLICATION FOR ADOPTION ORDER.

PART I SECTION A.

(To be completed only where the application is being made by a married couple).

We, the undersigned being a married couple living together, desire to adopt the child named or described in this application form. We understand that if an adoption order is granted to us in respect of the child, we shall be fully responsible for the child's upbringing as if the child were born to us in lawful wedlock and we voluntarily undertake to discharge that responsibility as far as we are able. We have not received or made, or agreed to receive or make, any payment whatsoever in consideration of the adoption of this child.*

Husband's signature.......................................................

Wife's signature............................................................ ..

Date............................................................ .........

*Payments made or received in respect of the child's maintenance or solicitors' remuneration for professional services are not referred to here.

PART I

SECTION B.

(To be completed where the application is being made by one person only).

I, the undersigned person, being the mother of the child/the natural father of the child/a relative* of the child/a widow

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Strike out the parts that do not apply.

desire to adopt the child named or described in this application form. I understand that if an adoption order is granted to me in respect of the child, I shall be fully responsible for the child's upbringing as if the child were born to me in lawful wedlock and I voluntarily undertake to discharge that responsibility as far as I am able. I have not received or made, or agreed to receive or make any payment whatsoever in consideration of the adoption of this child.*

Applicant's signature............................................................ .............

Date............................................................ ..........................

*" relative" here means grandparent, brother, sister, uncle or aunt, whether of the whole blood, of the half blood, or by affinity, relationship to an illegitimate child being traced through the mother only.

**Payments made or received in respect of the child's maintenance or solicitors remuneration for professional services are not referred to here.

PART II SECTION A.

(To be completed in every application. If the application is being made by a married couple, the particulars given should be those relating to the husband only).

1. Husband's/Applicant's name. (Strike out "husband's" or "applicant's," whichever does not apply)............................................................ ............................................................ .................................................

(Block letters).

2. Address............................................................ ............................................................ .................................................

(Block letters).

............................................................ ............................................................ ......................

3. Occupation............................................................ ............................................................ ............................................

4. Relationship (if any) to child............................................................ ............................................................ ..............

5. Date of birth............................................................ ............................................................ ...........................................

6. Place of birth............................................................ ............................................................ ..........................................

7. Are you residing in the State and, if so, since when?............................................................ ................................

8. Are you an Irish citizen ?............................................................ ............................................................ .....................

9. Religious denomination............................................................ ............................................................ .......................

PART II

SECTION B.

(This section is to be completed only where the application is being made by a married couple. The questions relate to the wife.)

10. Wife's name............................................................ ............................................................ ........................................

(Block letters).

11. Relationship (if any) to child............................................................ ............................................................ ..........

12. Date of birth............................................................ ............................................................ ......................................

13. Date and place of marriage............................................................ ............................................................ .............

14. Religious denomination............................................................ ............................................................ ..................

PART II

SECTION C.

(To be completed in every application).

15. Have you previously applied for an adoption order in respect of this or any other child and, if so, with what result?............................................................ ............................................................ .......................................

............................................................ ............................................................ ............................................................ .

16. (a) Have you any children of your own; if so, please give names, dates of birth and present addresses?............................................................ ............................................................ .........................................

............................................................ ............................................................ ............................................................ .

(b) Have you any other children in your care; if so, please give names and dates of birth?............................................................ ............................................................ ..........................................

............................................................ ............................................................ .....................................................

17. Name of child............................................................ ............................................................ ......................................

(Block letters).

18. Sex............................................................ ............................................................ ......................................................

19. Date of birth............................................................ ............................................................ ......................................

20. Is the child an orphan (both parents dead)?............................................................ ...........................................

21. Is the child illegitimate?............................................................ ............................................................ .................

22. If the child is already under your care please state—

(a) Name and address of person or body from whom you got it..........................................................

............................................................ ............................................................ .................................................

(b) Appropriate date on which you took it under your care............................................................ .......

23. If the child is not living with you, please state name and address of person or body having charge of it............................................................ ............................................................ ......................................................

............................................................ ............................................................ ........................................................

24. (a) Have you obtained the mother's consent to the adoption?............................................................ ..........

(b) Have you obtained the consent of the guardian(s) and of any other person or body having charge of or control over the child?............................................................ ...........................................................

............................................................ ............................................................ .........................................................

25. If the consents referred to at 24 (a) and (b) have not been obtained, do you ask the Board to dispense with them and, if so, on what grounds?............................................................ .................................................

26. If you are arranging to have the consents referred to in Questions 24 (a) and/or 24 (b) submitted to the Board by a person other than yourself, please state name and address of such person.............................

............................................................ ............................................................ ............................................................

............................................................ ............................................................ ............................................................ .

27. Please give the names and addresses (block letters) of two or more persons (either men or women) to whom reference may be made by the Board. Where the name of a woman is given as a reference it is preferable that she should be a mother or a woman with experience in the care of children...................

............................................................ ............................................................ ........................................................

Note:—The Board may require you to submit a medical certificate on your state of health before coming to a decision on your application.

Form 2.

PARTICULARS CONCERNING CHILD.

Note to Applicant: If you got the child from the mother or guardian you should fill this Form yourself. If you got the child from any other source you may fill this Form yourself or you may send it to the person or body who gave you the child and ask him to fill it and return it direct to the Registrar, An Bord Uchtála.

1. Name of child............................................................ .................................		Questions 1 to 6 on this page need not be answered where the form is being filled in by the applicant.
(Block letters)
2. Sex............................................................ ...................................................
3. Date of birth............................................................ ..................................
4. Is the child an orphan (both parents dead) ?.......................................
5. Is the child legitimate ?............................................................ ................

6. If the child is legitimate, state

(a) Father's name............................................................ ............................................................ ......................

(b) Approximate date of father's death............................................................ .............................................

(c) Father's religion at death............................................................ ............................................................ ...

(d) Mother's name............................................................ ............................................................ ....................

(e) Approximate date of mother's death............................................................ ..........................................

(f) Mother's religion at death............................................................ ............................................................ ...

7. If the child is illegitimate* state

(a) Mother's name............................................................ ............................................................ ..................

(b) Is the mother alive or dead?............................................................ ........................................................

(i) her address............................................................ ............................................................ .......

(ii) occupation............................................................ ............................................................ .......

(iii) date of birth, or if date is unknown, her approximate age..................................................

(iv) Religious denomination............................................................ ................................................

(v) Has the mother changed her religion at any time. If so, in what way, and give date of change?

(d) If the mother is dead, state

(i) approximate date of death............................................................ ..............................................

(ii) ordinary place of residence before her death (Block letters)

............................................................ ............................................................ .............................

*A child is not illegitimate if the natural parents have married each other after the child's birth (except in the rare case where they could not lawfully have married at the time of birth).

(iii) place of death (Block letters)............................................................ .....................................

(iv) Religious denomination at death............................................................ ...............................

(v) whether she had changed her religion at any time and, if so, particulars and date of change............................................................ ............................................................ ..............

(e) Did the mother marry since birth of child ?............................................................ ...............................

8. Name of person or persons, if any, who has or have been appointed by will or deed or by Court Order to be the guardian(s) of the child............................................................ ............................................................ .......

............................................................ ............................................................ ............................................................

(Block letters)

9. Address(es) of guardian(s) named in answer to question 8............................................................ ......................

............................................................ ............................................................ ............................................................ .

(Block letters)

10. If the child is under the control of a Public Assistance Authority or Registered Adoption Society state name and address of Public Assistance Authority or Registered Adoption Society, and date on which such body acquired control over the child............................................................ ..............................................

............................................................ ............................................................ ............................................................ .

11. Religion in which the child is being brought up............................................................ ........................................

Signature............................................................ ........................................................

Address............................................................ ..........................................................

............................................................ ..........................................................

Date............................................................ ............................................................ ......

Form 3.

CONSENT TO ADOPTION.

(For use where the identity of the applicant is known to the consenting party).

In the matter of an application for the adoption of............................................................ ................................

I,.....................(name and description) of................., aged, twenty-one years and upwards (or, if under age, aged............years) make oath and say as follows :—

1. I am aware that an application is about to be made or has been made

by ............................................................ ............................................of............................................................ .......

for an adoption order in respect of the child............................................................ ............................................

2. I am/the mother of the child/the guardian of the child/the person having charge of or control over the child/ (a)

3. The child is not less than six months old, having been born on the..........day.........................., 19 .

4. I am of the.........................religion, and this has been my religion since........................(to be completed by mother only).

5. I understand that the effect of an adoption order is to deprive me of all rights which I have in respect of the upbringing of the child, and to give these rights and all parental rights and duties to the adopter.

6. I hereby give my consent to the making of an adoption order in pursuance of the application referred to above.

7. I understand that this affidavit may be used as evidence that I consent to the adoption order being made.

Signature............................................................ ..........................

Sworn at............................in the county of.............................on this............................day of............................., 19........... before me,............................................................ ................... (name) and I know the deponent (or and I know............................................................ ...who certifies to me that he knows the deponent).

Signature............................................................ .................

Description (b).....................................................

(a) Strike out words which do not apply.

(b) If the affidavit is being sworn in the State, it should be sworn before a Commissioner for Oaths ; if it is being sworn elsewhere, it should be sworn before a Notary Public or other person duly authorised to administer oaths.

Form 4.

CONSENT TO ADOPTION.

(For use where the identity of the applicant is not known to the consenting party).

In the matter of an application for the adoption of.............................

I,............................ (name and description) of......................., aged twenty-one years and upwards (or, if under age, aged...............years) make oath and say as follows :—

1. I am informed and believe that an application has been made under serial number.......................... (a) for an adoption order in respect of the child............................................................ ..........

2. I am/the mother of the child/(b) the guardian of the child/(b) the person having charge of or control over the child/(b).

3. The child is not less than six months old, having been born on the...........day..............................., 19.......

4. I am of the..............................religion, and this has been my religion since............................(to be completed by the mother only).

6. I hereby give my consent to the making of an adoption order in pursuance of the application referred to above.

7. I understand that this affidavit may be used as evidence that I consent to the adoption order being made.

Signature............................................................ ..........................

Sworn at............................ in the county of....................., on this.....................day of..........................., 19.........., before me .....................................(name) and I know the deponent (or and I know ................... who certifies to me that he knows the deponent).

Signature............................................................ ..............

Description (c)..................................................

(a) Where the indentity of the applicant is not known to the consenting party the applicant should request the Board to assign a serial number to the application and this number should be inserted here.

(b) Strike out words which do not apply.

(c) If the affidavit is being sworn in the State, it should be sworn before a Commissioner for Oaths ; if it is being sworn elsewhere ; it should be sworn before a Notary Public or other person duly authorised to administer oaths.

Form 5.

INTERIM ORDER.

WHEREAS an application has been made to An Bord Uchtála (hereinafter called " the Board ") by....................by occupation................. and resident at........................................................and his wife*..........................hereinafter called the applicant/applicants* for an adoption order under the Adoption Act, 1952 (hereinafter called " the Act ") authorising him/her/them* to adopt........................* born on the......................* the probable date of whose birth has been determined by the Board to be the..................................... :

AND WHEREAS the Board is satisfied that the requirements of the Act with regard to the qualifications and suitability of the applicant/each of the applicants* to adopt the child and to the eligibility of the child to be adopted by the applicant/applicants* have been fulfilled :

AND WHEREAS all the consents required by the Act have been obtained or dispensed with in accordance with the provisions of the Act :

AND WHEREAS the Board is satisfied that the child is identical with .............................to whom the entry numbered.............................made on the...........day of............................ ,19........in the Register of Births for the District of..............................in the County of............... relates :

NOW THEREFORE, the Board orders as follows :—

1. This application shall stand adjourned until further order ;

2. The applicant/applicants* shall have custody of the child for a probationary period beginning on the......................and ending on the..............,* subject to the following conditions :

GIVEN under the Official Seal of the Board this..........day of .........................., 19.......

Chairman/Registrar* a person authorised by the Board to attest the seal of the Board,

*Delete if not applicable.

Form 5a.

INTERIM ORDER UNDER SECTION 19.

WHEREAS an application has been made to An Bord Uchtála (hereinafter called " the Board ") by...............................................by occupation........................................., and resident at......................... and his wife*.......................... hereinafter called the applicant/applicants* for an adoption order pursuant to Section 19 of the Adoption Act, 1952 , (hereinafter called " the Act ") authorising him/her/them* to adopt..............................* on the..........................* the probable date of whose birth has been determined by the Board to be the ........................................................... :

* WHEREAS on reasonable cause being shown by the applicant/applicants* the Board extended the time for making the application :

AND WHEREAS the Board is satisfied that the child has been under the care of the applicant/applicants* from a date before the passing of the Act and that the requirements of the Act with regard to the qualifications and suitability of the applicant/each of the applicants* to adopt the child and to the eligibility of the child to be adopted by the applicant/applicants* have been fulfilled :

AND WHEREAS the Board has given due consideration to the wishes of the child having regard to his/her* age and understanding :

AND WHEREAS all the consents required by the Act have been obtained or dispensed with in accordance with the provisions of the Act :

AND WHEREAS the Board is satisfied that the child is identical with .........................to whom the entry numbered............................made on the..............day of................, 19....... in the Register of Births for the District of.......................in the County of............... relates :

NOW THEREFORE the Board orders as follows :

1. this application shall stand adjourned until further order ;

2. the applicant/applicants* shall have custody of the child for a probationary period beginning on the.............................................and ending on the .............................,* subject to the following conditions :

GIVEN under the Official Seal of the Board this........day of ......................, 19.......

Chairman/Registrar* a person authorised by the Board to attest the seal of the Board.

*Delete if not applicable.

Form 6.

ADOPTION ORDER.

WHEREAS an application has been made to An Bord Uchtála (hereinafter called " the Board ") by..............................by occupation............. and resident at......................................... and his wife* ..............................hereinafter called the applicant/applicants* for an adoption order under the Adoption Act, 1952 , (hereinafter called " the Act ") authorising him/her/them* to adopt.................................* born on the........................../*the probable date of whose birth has been determined by the Board to be the.......................................................... :

AND WHEREAS the Board is satisfied that the requirements of the Act with regard to the qualifications and suitability of the applicant*/each of the applicants/to adopt the child and to the eligibility of the child to be adopted by the* applicant/applicants have been fulfilled :

AND WHEREAS all the consents required by the Act have been obtained or dispensed with in accordance with the provisions of the Act :

AND WHEREAS the Board is satisfied that the child is identical with ........................to whom the entry numbered....................made on the.....................day of.............., 19...... in the Register of Births for the District of........................in the County of.........................relates :

NOW, THEREFORE the Board orders the adoption of the child by the *applicant/applicants.

GIVEN under the Official Seal of the Board this............ day of......................., 19.................

Chairman/Registrar/* a person authorised by the Board to attest the seal of the Board.

*Delete words which do not apply.

Form 6a.

ADOPTION ORDER UNDER SECTION 19.

WHEREAS an application has been made to An Bord Uchtála (hereinafter called " the Board ") by............................................by occupation .................................., and resident at..........................and his wife*.....................................hereinafter called the applicant/applicants* for an adoption order pursuant to section 19 of the Adoption Act, 1952 , (hereinafter called " the Act ") authorising him/her/them* to adopt..............................* born on the...........................* the probable date of whose birth has been determined by the Board to be the.............................................. :

*AND WHEREAS on reasonable cause being shown by the applicant/applicants* the Board extended the time for making the application :

AND WHEREAS the Board has given due consideration to the wishes of the child having regard to his/her* age and understanding :

AND WHEREAS all the consents required by the Act have been obtained or dispensed with in accordance with the provisions of the Act :

AND WHEREAS the Board is satisfied that the child is identical with ...........................to whom the entry numbered...........................made on the..........................day of........................,19......in the Register of Births for the District of...........................in the County of........................relates :

NOW, THEREFORE the Board orders the adoption of the child by the applicant/applicants.*

GIVEN under the Official Seal of the Board this...........day of......................., 19.......

Chairman/Registrar/*a person authorised by the Board to attest the seal of the Board.

*Delete words which do not apply.

Form 7.

PARTICULARS TO BE SENT TO AN tÁRD-CHLARAITHEÓIR UNDER SECTION 22 (8) OF ADOPTION ACT, 1952 .

Date and Country of birth	Christian name or first name	Sex	Name, Address and occupation of adopter or adopters	Date of Adoption Order	Entry relating to child in Register of Births

Form 8.

APPLICATION FOR REGISTRATION OF ADOPTION SOCIETY.

I, the undersigned person, being duly authorised on behalf of the Adoption Society called................................hereby apply to an Bord Uchtála (hereinafter called " The Board ") to have the Society registered under the Adoption Act, 1952 , as an adoption society. The following are particulars of the society :

1. Address of Society's headquarters............................................................ ...................................................

(Block letters).

............................................................ ............................................................ .......................................................

2. Date of establishment............................................................ ............................................................ ...............

3. Objects of the Society. [A copy of the Society's constitution or other instrument (if any) governing its activities should be attached]............................................................ ............................................................ ..........

4. Full names, addresses, occupations and/or descriptions of

(a) all members of the Committee controlling the activities of the Society and
		(a)	attach separate lists.
(b) all person employed by the Society, whether voluntary or paid, on work connected with adoption.	(b)

5. Has the Society under its control any home, hostel, orphanage or other such institution in which children under the age of seven years are maintained ?

............................................................ ............................................................ ........................................................

6. If the answer to question 5 is " yes," state

(a) The address of such Institution............................................................ ..................................................

............................................................ ............................................................ ............................................

............................................................ ............................................................ .............................................

(b) Whether it is exclusively an institution for children (if not, give brief particulars) and whether it is exclusively for boys or exclusively for girls ............................................................ ........................

institution ............................................................ ............................................................ .........................

(d) Approximate number of children normally in the institution............................................................ ...

(e) In what religion the children are brought up............................................................ .............................

(f) How the institution is mainly financed............................................................ ........................................

(g) Whether the Society, if registered, propose to concern themselves only with the children in this institution if not, give brief particulars.

............................................................ ............................................................ ............................................

7. If the answer to question 5 is " no," state briefly how the Society propose to function as a registered Adoption Society—in what children they propose tointerest themselves or in what circumstances do they propose to arrange adoptions............................................................ ............................................................ ......

............................................................ ............................................................ ............................................................

The Society hereby undertake, if registered, to make available to the Board, when requested, in relation to any and every child with whose proposed adoption the Society is concerned, all material facts known to the Society relating to the child, and to the proposed adopters, for the assistance and guidance of the Board prior to the making of an adoption order.

STATUTORY DECLARATION.

I,............................................................ ................ do solemnly and sincerely declare that the foregoing particulars stated in this application are true and I make this solemn declaration conscientiously believing the same to be true and by virtue of the Statutory Declarations Act, 1938 .

Signature............................................................ ..............................................

Office held in the Society............................................................ .................

Address............................................................ ................................................

............................................................ ................................................

Date............................................................ ................................................

Declared before me(a)............................................................ ....................................by the said applicant who is personally known to me (or who is identified to me, by............................................................ ..................

who is personally known to me) at............................................................ ............................................................ ......

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

Description............................................................ ....................................

This.........................................day of.....................................,19......

(a) This declaration should be made before a Notary Public or a Commissioner for Oaths or a Peace Commissioner.

Form 9.

FORM OF ENTRY IN ADOPTION SOCIETIES' REGISTER.

Serial No.	Name of Society	Address of Society's Headquarters	Name and address of Chairman/ President of Society	Name and address of Secretary of Society	Date of Application for registration	Date of registration	Remarks

Form 10.

ADOPTION ACT, 1952 .

Memorandum to be furnished by a registered Adoption Society to a mother or guardian who proposes to place a child at the disposal of a registered Adoption Society.

If an adoption order is made in respect of the child, all your rights and duties in regard to the child will be transferred permanently to the adopters. The child will be regarded as the child of the adopters and you will have no right to get it back later on, even if you can then prove that you are able to give it a better home than the adopters can. If you have an insurance policy against funeral expenses for the child, the policy will be transferred to the adopters and it will be for them to pay the premiums from then onwards. If the child is illegitimate and the natural father is making any payments for the child's benefit, either under an agreement or under an affiliation order, he will not be legally bound to continue these payments, unless the mother is the adopter.

The Board which deals with adoptions will not make an adoption order without the consent of the child's mother or guardian, unless the mother or guardian cannot be found (or is unable to give consent because of mental infirmity). In order to ensure, therefore, that you will be informed of any proposal to have the child adopted, you should notify the Society of any change in your address. If you do not do this, it may not be possible to trace you, and the adoption order may be made without your consent.

(Perforate on this line).

............................................................ ............................................................ ............................................................ .........

(Detach here).

To the Registered Adoption Society called............................................................ .....................................................

............................................................ ............................................................ ............................................................ ...

I, the mother/guardian* of the child, have received from you a statement explaining the effects of an adoption order. That statement was attached to this receipt and I have myself torn it off. I understand that statement.

Name (in block letters)............................................................ ...........................................................

Signature............................................................ ............................................................ .....................

Address............................................................ ............................................................ ........................

............................................................ ............................................................ ........................

Signature of Witness............................................................ ............................................................ .

Address............................................................ ............................................................ .......................

............................................................ ............................................................ .......................

Occupation or Description............................................................ ...................................................

*Strike out words which do not apply.

Form 11.

NOTICE OF MAKING OF ADOPTION ORDER.

(To be published by the Board in Iris Oifigiúil).

In pursuance of the powers vested in it by the Adoption Act, 1952 (No. 25 of 1952), An Bord Uchtala has made an order for the adoption of a child............... (here insert Christian name of child) by........................................... (here insert name(s) and address of adopter(s).

Form No. 12.

NOTICE OF REGISTRATION OF ADOPTION SOCIETY.

(To be published by the Board in Iris Oifigiúil).

An Bord Uchtála has registered....................................................in the Adoption Societies Register.

Form No. 13.

NOTICE OF CANCELLATION OF REGISTRATION OF ADOPTION SOCIETY.

(To be published by the Board in Iris Oifigiúil).

An Bord Uchtála has cancelled the registration of.....................................................the Adoption Societies Register.

Form 14.

AN BORD UCHTÁLA

It has been represented to An Bord Uchtála that you can give evidence in the matter of an application for an Adoption Order by............................................................ ............................................................ ..................

You are hereby required to attend as a Witness on the hearing of the said application to be held at....................................on the..............................day of..............................19........., at.....................o'clock and on any day to which the hearing of the said application shall be ordered, and to bring with you the following documents............................................................ ............................................................ .............................................

............................................................ ............................................................ ............................................................ .....

GIVEN under the Official Seal of the Board this........................................................ day of........................................................, 19..........

Chairman/Registrar/ a person authorised by the Board to attest the Seal of the Board.

To: ...............................................

...............................................

Note : If you do not obey this Summons you are liable on summary conviction to a fine not exceeding Twenty-five Pounds.

Form 15.

MEDICAL REPORT* ON HEALTH OF APPLICANT.

(This form is to be completed where the adoption order has been applied for by one person only).

Name of Applicant............................................................ ...................................................Age....................................

Address............................................................ ............................................................ .....................................................

How long have you known him/her?............................................................ ............................................................ ....

Do you consider that the general health of the applicant is such that he/she would be suitable as an adopter? If not, please state why............................................................ ............................................................ ...........

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

Address............................................................ ...........................................

............................................................ ...........................................

*The Applicant shall arrange to have this report completed by a registered medical practitioner.

Form 16.

MEDICAL REPORT* ON HEALTH OF APPLICANT.

(This form is to be completed in respect of the wife where the adoption order has been applied for by a married couple).

Name of Applicant............................................................ ............................................................ ........... Age...............

Address............................................................ ............................................................ .....................................................

How long have you known her ?............................................................ ............................................................ ...........

Do you consider that the general health of the applicant is such that she would be suitable as an adopter? If not, please state why............................................................ ............................................................ ....................

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

Address............................................................ .....................................................

............................................................ .......................................................

*The Applicant shall arrange to have this report completed by a registered medical practitioner.

Form 17.

MEDICAL REPORT* ON HEALTH OF APPLICANT.

(This form is to be completed in respect of the husband where the adoption order has been applied for by a married couple).

Name of Applicant............................................................ ............................................................ ........... Age...............

Address............................................................ ............................................................ .....................................................

How long have you known him ?............................................................ ............................................................ ..........

Do you consider that the general health of the applicant is such that he would be suitable as an adopter? If not, please state why............................................................ ............................................................ .......................

............................................................ ............................................................ ............................................................ .........

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

Address............................................................ ............................................................ .......

*The Applicant shall arrange to have this report completed by a registered medical practitioner.

GIVEN under the Official Seal of the Board, this 6th day of March, 1953.

(Signed) D. Ua DONNCHADHA.

Chairman.

I consent to the foregoing rules

GIVEN under my Official Seal, this 11th day of March, 1953.

(Signed) GERALD BOLAND,

Minister for Justice.