I, ________________________ understand the potential risks involved in participating in a rigorous physical exercise program.

I assume the responsibility and risks as explained to me. I understand that participating in an exercise program may include, but not be limited to, serious bodily injury, heart attack, stroke, or even death.

I consent voluntarily to participate in an exercise program based on the information provided to me.

Name: ________________________________________________

Signature: ________________________________________________

Date: ________________________________________________

Witness: ________________________________________________