PEC 6 CONCUSSION AND HEAD INJURY INFORMATION SHEET

ACKNOWLEDGEMENT OF RECEIPT AND REVIEW
2019-2020 CONCUSSION AND HEAD INJURY
INFORMATION SHEET

Pursuant to Assembly Bill 25, which became effective January 1, 2012, the
student and parent/guardian shall sign this notice and return it to the school.
Signature on the notice is acknowledgement by the student and parent/guardian
that he or she has been informed about the concussion information.

Please sign the “Acknowledgement of Receipt and Review Form” below and
return it to your student’s school.

_________________________ ____________________________ ______
Student-Athlete Name Printed
Student-Athlete Signature Date

_________________________ ____________________________ ______
Parent/Legal Guardian Printed Parent/Legal Guardian Signature Date