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I _________________________ certify and acknowledge:

1) That Maria D'Agostino, an independent Personal Trainer, has advised
me, prior to my commencement of participation in a cardiovascular and
weight training program, that such participation could result in
physical injury.

2) That I _____________________ freely and knowingly
assume the risks in such program and I hereby waive any
right, claim or cause of action against Maria D'Agostino and release
her from any liability for any injury, cost, damage, expense or claim,
which I or anyone on my behalf might have as a direct or indirect result
of my participation in this cardiovascular and weight training program.

3) That:I ________________________ have read the foregoing, understand
and agree with each of the foregoing and have received a copy of this
Release Form on the date described below.

Print Name _________________________

Date _____________________

Signature __________________________

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