2022-2023 Middle School Activities Participation Booklet

Last Updated: 8/9/2022 2:58 PM

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MIDDLE SCHOOL ACTIVITIES PARTICIPATION BOOKLET 2021-22 SCHOOL YEAR
BELGRADE SCHOOL DISTRICT #44 BELGRADE MIDDLE SCHOOL GRADES 5-8

 

Please go to www.bsd44.org and read the Middle School Activities Policy that governs all Belgrade Middle School activities. After reading its contents, download and print the Student/Athlete & Parent/Legal Guardian Signature Booklet and return to the Middle School Office along with Participation Fee.

Physicals must be dated on or after May 1, 2022 per MHSA rules. Physical exams must be completed prior to the first practice and are only good for ONE school year.

 

TO:                  Parents of Student/Athletes
FROM:            Koby Ruff, Director of Activities
RE:                  Sports Participation Forms

Thank you for allowing your son or daughter to participate in our Activities Program. The Activities Program is designed to enhance the educational process by helping them to experience the many challenges that present themselves in interscholastic competition or by being involved in extracurricular activities. Our programs are for the student’s enjoyment and growth. The coaches, sponsors and I look forward to the opportunity to serve them.

If you have any questions, please call the Middle School Office 924-2207.

Student-athletes are required to get a physical and complete a participation booklet each school year. Please read all the information carefully, sign where appropriate, and turn in the entire Signature Booklet with the appropriate fees to the Middle School Office before the first day of practice. The Middle School Office is open from 8:00 am to 4:00 pm Monday through Friday.

COMPLETION OF DRAGONFLY PROFILE ALONG WITH THE PHYSICAL AND FEES ARE REQUIRED BEFORE THE FIRST PRACTICE!

  • Both Students and Parents Must Sign and Date the following pages found online in the back portion of the Middle School Activities Participation Handbook.
  • Acknowledgement of Activity Policies/Informed Consent and Insurance Status Verification Form Medical Treatment/Release form
  • *Physical Form - Student signature on front and parent signature on back
  • *Student-Athlete & Parent/Legal Guardian Concussion Statement

*= Needed for athletic participation only

PHYSICALS MUST BE COMPLETED BY A PHYSICIAN, PHYSICIAN ASSISTANT, OR NURSE PRACTITIONER DATED MAY 1, 2021 OR AFTER.

The participation fees may be refunded to students who do not make the team or choose to drop the sport prior to the 1st competition date. Refunds are not automatically mailed out. Students or parents must contact the Middle School Office to request a refund. Refunds will be issued by the school finance office and mailed directly to the parent on file – please check to make sure this information is correct. Thank you for your support and cooperation!

 

ACTIVITIES POLICY BELGRADE SCHOOL DISTRICT #44

PHILOSOPHY

The Belgrade School District provides a wide range of extra-curricular activities for both boys and girls. Participation in these activities is voluntary. We feel participation in these activities can bring students many rewards. Participation requires the student to make a commitment to the activity, submit to the discipline of the coach, activities director, or advisor, and develop self- discipline to be successful. Participation requires considerable mental discipline and/or physical exertion and conditioning, as well as adherence to training rules and team or group regimens.

We feel involvement in school activities provides students with an opportunity to be involved in a constructive endeavor. Students who are involved in activities tend to be good citizens and perform better in the academic arena. They go away from their high school careers with a more positive feeling about their experiences. We believe parents should encourage their children to get involved in these activities as well as support them as they experience the challenges of their chosen endeavors.

PURPOSE

Belgrade School District believes that participation in extracurricular activities is a privilege extended to students who are willing to make a commitment to adhere to the rules that govern the program. It is the district’s belief that participation in organized activities can contribute to the all-around development of young men and women and implementation of the rules will serve the following purposes:

  1. To emphasize concern for the health and wellbeing of students.
  2. To provide a chemical-free environment that will encourage development of a healthy life-style.
  3. To promote self-discipline and a commitment to excellence among students.
  4. To confirm and support existing state laws which prohibits use of mood-altering chemicals and performance enhancing drugs.
  5. To emphasize standards of conduct in our students who, through their participation, are leaders and role models for their peers and younger students.
  6. To assist students who desire to resist peer pressure, which often directs them toward the use of chemicals.

POLICY COVERAGE

The provisions of this policy include all students who are participating in any activity that is in addition to classroom instruction and have no bearing on course credit. This includes all athletics or any co-curricular clubs sponsored by Belgrade Schools. The adherence to this policy begins on the first day of their participation in any activity.

ACADEMIC ELIGIBILITY FOR PARTICIPATION

Belgrade Schools further stipulate:

Academics are the first responsibility of the student. Students are not in school for extra curricular activities, but are in extracurricular activities because of school. 

Local eligibility standards— All cases of eligibility arising that are not specifically provided for in this handbook shall be subject to the judgment of the school administrator. The administration’s decision will be final. Students must be in school the day of the activity in order to participate in that activity. 

Eligibility for extracurricular activities will be determined based on minor and major behaviors. On the Wednesday before a game or event, the list of minor and major behavior referrals will be pulled for student participants. Three minor behaviors or one major behavior infraction within the week will result in a student being on probation for the following week. Staff will inform the student-athlete and ask them to contact parents. During the probationary week, the coach/advisor will meet with the student to reinforce expectations and the student may not receive any further behavior referrals (minor or major) in order to remain eligible for the next game/event. Ineligible students are still expected to attend and participate in practices. They are allowed to attend home events, but not to dress out or participate. They are not allowed to travel with the team.

  • Physical Exam: Physical examination forms must be completed and turned in for all athletic activities before the student can begin practices. The current physical exam form is found in the participation booklet available on-line on or district’s home page or at the Belgrade Middle School Office.
  • Parent Meeting: Parents/guardians and students participating in an activity are invited to attend an informational meeting to discuss and sign the activities policy. Parents are asked to attend these meetings for each activity. Family members and fans of Belgrade Middle School student/athletes agree to serve as positive role models, treat all involved with respect, be supportive and encouraging. There will be no toleration of unsportsmanlike behavior and if such behavior occurs this person will be asked to leave immediately and may also lose permission to attend future events.
  • School Absences: Absences from school and participation in practices, games, meets or performances. 
    • If you are absent from school for a school sponsored event you can practice, play in a game, or take part in a performance that day. 
    • If you are absent from school for a limited number of periods for a medical, dental, optometrist, etc. appointment you can participate with approval from the administration (principal, vice principal, or the activities director). A written excuse from the doctor is required.
    • You may attend practice, play in games, or participate in performances with administrative approval if absent for a court appearance, bereavement, a family emergency, or some other reason deemed acceptable by the administration.
    • If you are home sick and do not come to school for all or part of the day or are absent from any class (excused or unexcused) you cannot practice, play, or participate in performances. It is not in the best interest of our participants to be practicing when sick.
    • If you are in school but are absent from class for reasons deemed unexcused, you may not participate in games, practices, or performances that day.
  • School Suspension: School suspension includes suspension from school sponsored extracurricular activities. This will be treated as an unexcused absence from the activity.
  • Participation Fee Required: All students participating in middle school athletics will be required to pay a $50 per sport activities in 7th & 8th grades and $25 in 5th & 6th grades. The money raised from this fee helps with the financial support of the activity that the student benefits from, though it pays for only a small portion of the actual expenses of the activity. (Scholarships are available. Please inquire at the Middle School Office!)

CODE OF CONDUCT

All participants shall abide by a code of conduct, which will earn them the honor and respect that participation and competition in the interscholastic program affords. Any conduct that results in dishonor to the student, team, group, or the school will not be tolerated.

Behavioral Expectations: All activities participants will be expected to conform to all rules of conduct formulated by the coaches/advisors/directors, activities director, administration, and school board, including all expectations outlined in the Belgrade Middle School Student Handbook. Participants may be suspended from the squad or group for any action unbecoming of a participant representing Belgrade Schools.

Activities participants should conduct themselves in an exemplary manner at all times. Belgrade Schools adheres to MHSA guidelines relating to the behavior of participants and spectators.

  1. Travel Requirements: All participants must travel to and return from all out of town activities with the team unless prior written permission is asked by their parents and granted by the administration. Participants will be released to travel with their parent/guardian only, after signing out with their coach/sponsor.
  2. Practice Expectations: All participants must attend all practices unless excused ahead of time by the coach/advisor/director. Unexcused absences will result in disciplinary actions as determined by the coach/advisor/activity director.
  3. Injuries: All injuries are to be reported immediately to the coach/advisor/activity director regardless of the nature of the injury. The coach/advisor/director will fill out an accident report form and file it in the principal’s office within one (1) school day of the accident.
  4. Confidentiality: Student report of a training rule violation will be held confidential.
  5. Hazing: Participating students will not be involved in hazing of other students. Hazing is defined as any intentional, knowing, or reckless act directed against a student for the purpose of being initiated into, affiliated with, holding office in, or maintaining membership in a club or organization, or an athletic team whose members include other students. Participants will not force other members of a team or organization to do something that could be distasteful or dangerous. Students who are involved in hazing could be suspended from participation and possibly referred to law enforcement.
  6. Liability: The coach/advisor/director, any other member of the school staff, or any member of the Board of Trustees will not be held liable or responsible in case of an accident incurred during practice, games, meets, matches, tournaments, concerts, or trips supervised by Belgrade Public Schools.
  7. Serious Infractions: Participants charged with serious misdemeanors or felonies may be suspended from the activity pending disposition of the case. Following a conference with administration, head coach/advisor/director, activities director, and parents/guardian, the individual case shall be acted upon.

CHEMICAL USE POLICY/VIOLATIONS

Participants must abide by the terms of the District’s Chemical Dependency Prevention Policy and the following terms of this Activities Policy:

  1. No drinking or possession of alcoholic beverages
  2. No use or possession of illegal drugs or drug paraphernalia
  3. No use or possession of tobacco, nicotine products, or vaping materials in any form
  4. No attendance at a party where alcohol/drugs are consumed

Violations will be cumulative from the student’s first day of participation in any activity in the middle school and again at the high school. A record of all violations will be kept by the activities director or the middle school principal.

  • Middle School: The accumulation of offenses starts in fifth grade and continues through the eighth grade. Participants will no longer be eligible to participate after a second violation during their middle school experience.
  • High School: The violation count starts anew upon entering the freshman year and continues through the participant’s senior year. Students will be dropped from participation if they receive three violations during this time period.

Students who are found in violation of the chemical use policy at a school-sponsored event or on school sponsored trips will be disciplined under the provisions of the school discipline policy as well as the activities policy.

Honesty Clause: Participants who violate the chemical use policy and admit to infractions will be penalized as stated per violation. Participants who deny that they have broken the chemical use policy and are later found guilty of violations will automatically be penalized by advancing to the next numerical step violation consequence.

In addition, all participants are subject to the following consequences for violation of this policy:

  • FIRST VIOLATION: (DRUGS/ALCOHOL/TOBACCO): Participants will be ineligible to compete in any games, contests, or performances for ten (10) school days from the date of disciplinary action. They will not be allowed to travel or sit with the team or group during performances or contests during this time. In addition, participants must attend and successfully complete the first available Minor in Possession/Alcohol Education Class (MIP/AEC) for drug and alcohol violations; or equivalent on-line course approved by administration if a local option is not available. Participation in these classes will be at their expense. Participants will continue to practice. The 10 school days will be carried over to the next activity and or school year.
  • SECOND VIOLATION HIGH SCHOOL ONLY: (DRUGS/ ALCOHOL/TOBACCO): Participants will be suspended for 20 school days from the date of disciplinary action. They will not be allowed to travel or sit with the team or group during performances or contests. In addition, participants must attend and successfully complete the first available Minor in Possession /Alcohol Education Class (MIP/AEC) for drug/alcohol violations; or equivalent on- line course approved by administration. Another approved program may be substituted for these classes. Participation in these classes will be at their expense. Participants will regain eligibility provided they have successfully completed the class and follow any and all recommendations made by the MIP/AEC class leader to become eligible to participate in another activity. If the first available MIP/AEC is not successfully completed, the participant will lose his/her eligibility until an MIP/AEC is successfully completed. The 20 school days will be carried over to the next activity and or school year.
  • THIRD VIOLATION HIGH SCHOOL OR SECOND VIOLATION MIDDLE SCHOOL: (DRUGS/ALCOHOL/TOBACCO): Students will be suspended from all extra-curricular activities for the remainder of their middle school or high school career. Students may be reinstated by agreeing to a chemical dependency assessment and following the recommendations made by the chemical dependency counselor. The student must provide the results of his/her assessment to the activities director and principal. The activities director and principal will meet with the student and his/her parents/guardians to determine appropriate action. Students eligible for reinstatement will be suspended for a minimum of 60 school days. The 60 school days will be carried over to the next school year.

DUE PROCESS

  1. The coach/advisor/director has the authority and the responsibility to suspend any participant from practice or competition for violation of activities policy until a meeting is arranged with parents or guardians. The coach/advisor/director or activities director will contact the parents/guardians within 24 hours if a participant is suspended.
  2. The coach/advisor/director or activities director has the authority to investigate if he/she suspects violation of the activities policy.
  3. Due process will be followed in each disciplinary case. The student and the coach/advisor/director will meet in conference with the parents or guardians prior to a student being dismissed from the team for a violation of training rules. The meeting will take place with the principal and/or activities director at the earliest convenient time.

INVOLVEMENT PROCEDURE

The purpose of this procedure is to encourage positive development of lifetime problem-solving skills. If a participant and/or parent/guardian have a concern with the activity in which the student is involved, they should communicate in the following order:

Team Coach>Head Coach/Advisor/Director>Activities Director>Building Principal>Superintendent>School Board

HOTEL BEHAVIOR

Students must obey curfew set by coaches and chaperones and be in their assigned hotel rooms on all school sponsored trips. Students may not be found in a room of the opposite gender and/or with someone they are romantically involved at any time.

CONCUSSION INFORMATION

Please read the following concussion information pages provided by the MHSA.

A Fact Sheet for ATHLETES

WHAT IS A CONCUSSION?

  • A concussion is a brain injury that:
  • Is caused by a bump or blow to the head
  • Can change the way your brain normally works
  • Can occur during practices or games in any sport
  • Can happen even if you haven’t been knocked out
  • Can be serious even if you’ve just been “dinged”

WHAT ARE THE SYMPTOMS OF A CONCUSSION?

  • Headache or “pressure” in head
  • Nausea or vomiting
  • Balance problems or dizziness
  • Double or blurry vision
  • Bothered by light
  • Bothered by noise
  • Feeling sluggish, hazy, foggy, or groggy
  • Difficulty paying attention
  • Memory problems
  • Confusion
  • Does not “feel right”

WHAT SHOULD I DO IF I THINK I HAVE A CONCUSSION?

  • Tell your coaches and your parents. Never ignore a bump or blow to the head even if you feel fine. Also, tell your coach if one of your teammates might have a concussion.
  • Get a medical checkup. A doctor or health care professional can tell you if you have a concussion and when you are OK to return to play.
  • Give yourself time to get better. If you have had a concussion, your brain needs time to heal. While your brain is still healing, you are much more likely to have a second concussion. Second or later concussions can cause damage to your brain. It is important to rest until you get approval from a doctor or health care professional to return to play.

HOW CAN I PREVENT A CONCUSSION?

  • Every sport is different, but there are steps you can take to protect yourself.
  • Follow your coach’s rules for safety and the rules of the sport.
  • Practice good sportsmanship at all times.
  • Use the proper sports equipment, including personal protective equipment (such as helmets, padding, shin guards, and eye and mouth guards).

In order for equipment to protect you, it must be:

  • The right equipment for the game, position, or activity
  • Worn correctly and fit well
  • Used every time you play

Remember, when in doubt, sit them out!

It’s better to miss one game than the whole season!

A Fact Sheet for PARENTS

WHAT IS A CONCUSSION?

A concussion is a brain injury. Concussions are caused by a bump or blow to the head. Even a “ding,” “getting your bell rung,” or what seems to be a mild bump or blow to the head can be serious.

You can’t see a concussion. Signs and symptoms of concussion can show up right after the injury or may not appear or be noticed until days or weeks after the injury. If your child reports any symptoms of concussion, or if you notice the symptoms yourself, seek medical attention right away.

WHAT ARE THE SIGNS AND SYMPTOMS OF A CONCUSSION?

Signs Observed by Parents or Guardians

If your child has experienced a bump or blow to the head during a game or practice, look for any of the following signs and symptoms of a concussion:

  • Appears dazed or stunned
  • Is confused about assignment or position
  • Forgets an instruction
  • Is unsure of game, score, or opponent
  • Moves clumsily • Answers questions slowly
  • Loses consciousness (even briefly)
  • Shows behavior or personality changes
  • Can’t recall events prior to hit or fall
  • Can’t recall events after hit or fall

Symptoms Reported by Athlete

  • Headache or “pressure” in head
  • Nausea or vomiting
  • Balance problems or dizziness
  • Double or blurry vision
  • Sensitivity to light
  • Sensitivity to noise
  • Feeling sluggish, hazy, foggy, or groggy
  • Concentration or memory problems
  • Confusion
  • Does not “feel right”

HOW CAN YOU HELP YOUR CHILD PREVENT A CONCUSSION?

Every sport is different, but there are steps your child can take to protect themselves from concussion.

  • Ensure that they follow their coach’s rules for safety and the rules of the sport.
  • Encourage them to practice good sportsmanship at all times.
  • Make sure they wear the right protective equipment for their activity (such as helmets, padding, shin guards, and eye and mouth guards). Protective equipment should fit properly, be well maintained, and be worn consistently and correctly.
  • Learn the signs and symptoms of a concussion.

WHAT SHOULD YOU DO IF YOU THINK YOUR CHILD HAS A CONCUSSION?

  1. Seek medical attention right away. A health care professional will be able to decide how serious the concussion is and when it is safe for your child to return to sports.
  2. Keep your child out of play. Concussions take time to heal. Don’t let your child return to play until a health care professional says it’s OK. Children who return to play too soon— while the brain is still healing—risk a greater chance of having a second concussion. Second or later concussions can be very serious. They can cause permanent brain damage, affecting your child for a lifetime.
  3. Tell your child’s coach about any recent concussion. Coaches should know if your child had a recent concussion in ANY sport. Your child’s coach may not know about a concussion your child received in another sport or activity unless you tell the coach.

Remember, when in doubt, sit them out!

It’s better to miss one game than the whole season.

Be Prepared

A concussion is a type of traumatic brain injury, or TBI, caused by a bump, blow, or jolt to the head that can change the way your brain normally works. Concussions can also occur from a blow to the body that causes the head to move rapidly back and forth. Even a “ding,” “getting your bell rung,” or what seems to be mild bump or blow to the head can be serious. Concussions can occur in any sport or recreation activity. So, all coaches, parents, and athletes need to learn concussion signs and symptoms and what to do if a concussion occurs.

LINKS TO OTHER RESOURCES

Health Insurance

The School District DOES NOT provide medical insurance benefits for students who choose to participate in activities programs.

If parents or guardians have their own insurance coverage during the student’s participation, that coverage information should be provided on the required “Informed consent and Insurance verification” form.

If the student/athlete does not have current health insurance and wishes to purchase coverage or additional coverage, the district has cooperated with K & K Insurance to provide families with an option to purchase health coverage for the duration of the sport season or school year. If the family chooses to sign up with K & K Insurance the enrollment information is below.

2021-2022 Student Accident Coverage

Serviced by K&K Insurance Group, Inc. 
Phone: 855-742-3135

Remember to visit our website for faster enrollment: www.studentinsurance-kk.com
Open Enrollment - Secured accident Coverage can be purchased anytime throughout the year.

Accident Only Coverage:  The Policy provides benefits for loss due to covered injury up to the Maximum Benefit of $25,000 for each injury.  Provided that treatment by a qualified, licensed Physician begins within 60 days from date of injury,  benefits will be paid for Covered Medical Expenses incurred within 52 weeks from the date of injury up to the Maximum Benefit per service as shown below.

Schedule of Benefits: Maximum Benefits Paid As Specified Below.
Compare and Choose Low Option Accident Only High Option Accident Only
Maximum Benefit: $25,000 (For Each Injury) $25,000 (For Each Injury)
Deductible: $0 $0
Inpatient Hospital Services    
Room & Board Expenses: Up to $150 per day/
Semi-private room rate
80% of Usual and Customary Charges/
Semi-private room rate
Miscellaneous Expenses: $600 maximum per day $1,200 maximum per day
Physician’s Visits:
(Limited to one visit per day)
$40 first day/$25 each subsequent day $60 first day/$40 each subsequent day
Ambulatory Medical Center $1,000 maximum $1,200 maximum
Emergency Room Treatment:
(Treatment must be rendered within 72 hours from the time of the injury)
$150 maximum $300 maximum
Surgery
(*Allowance is calculated: 100% of Usual and Customary Charges for the 1st procedure, 50% of
Usual and Customary Charges for the 2nd procedure, and 25% of Usual and Customary Charges for
each additional procedure when performed through different incisions/portals.)
$1,000 maximum $1,200 maximum
Assistant Surgeon 100% of Usual and Customary Charges
(*Allowance is calculated: 20% of the surgical maximum for the surgery performed as indicated above.)
100% of Usual and Customary Charges
(*Allowance is calculated: 25% of the surgical maximum for the surgery performed as indicated above.)
Anesthesia and its Administration 100% of Usual and Customary Charges
(*Allowance is calculated: 20% of the surgical maximum for the surgery performed as indicated above.)
100% of Usual and Customary Charges
(*Allowance is calculated: 25% of the surgical maximum for the surgery performed as indicated above.)
Outpatient    
Outpatient Physician Visits:
(Limited to one visit per day)
$40 first day/$25 each subsequent day $60 first day/$40 each subsequent day
Outpatient X-ray: $200 maximum $600 maximum
Outpatient Diagnostic Imaging Services: $300 maximum $600 maximum
Outpatient Laboratory: $50 maximum $300 maximum
Outpatient Physiotherapy:
(Limited to one visit per day. Includes acupuncture; microthermy; manipulation; diathermy; massage therapy; heat treatment; and ultrasonic treatment)
$30 first day/$20 each subsequent day/
5 days maximum
$60 first day/$40 each subsequent day/
5 days maximum
Ambulance Services:
(Air and Ground)
$300 maximum $800 maximum
Medical Equipment Rental:
(Includes Orthopedic devices)
$75 maximum $140 maximum
Dental Services: $10,000 maximum per policy $10,000 maximum per policy term
Prescription Drugs: $75 maximum $200 maximum
Consultant: $200 maximum $400 maximum
Replacement of Eye Glasses, Contact Lenses or Hearing Aids: 100% of Usual and Customary Charges 100% of Usual and Customary Charges

THIS IS A BLANKET ACCIDENT ONLY POLICY.

U.S. Insurance coverage is underwritten by AXIS Insurance Company under group policy form series number BACC-001-0909, et al. Coverage is subject to exclusions and limitations, and may not be available in all US states and jurisdictions. Product availability and plan design features, including eligibility requirements, descriptions of benefits, exclusions or limitations may vary depending on local country or US state laws. Full terms and conditions of coverage, including effective dates of coverage, benefits, limitations, and exclusions, are set forth in the policy.
The amount of benefits provided depends upon the plan selected; the premium will vary with the amount of the benefits selected.

THIS INSURANCE DOES NOT COORDINATE WITH ANY OTHER INSURANCE PLAN. IT DOES NOT PROVIDE MAJOR MEDICAL OR COMPREHENSIVE MEDICAL COVERAGE AND IS NOT DESIGNED TO REPLACE MAJOR MEDICAL INSURANCE. FURTHER, THIS INSURANCE IS NOT MINIMUM ESSENTIAL BENEFITS AS SET FORTH UNDER THE PATIENT PROTECTION AND AFFORDABLE CARE ACT.

Choose Your Coverage Plan: One-Time Payment For Accident Coverage

PLEASE NOTE - FOR COVERAGE PLANS LISTED BELOW

Coverage Effective Date: A person’s coverage takes effect at the later of the date his or her completed student accident enrollment form and premium is received by the company or the effective date of the policy issued to his or her school or school district.

Coverage Termination Date: Coverage ends on the earlier of the date his or her coverage has been in force for twelve months or the first day of the next school year. All coverage ceases if the policyholder cancels the policy or when the person ceases to be an eligible person per the definition below. Termination of coverage for any reason will not affect a claim which occurs before coverage ends.

  Low Option High Option

24-Hour Accident
Around-the-clock. Before, during and after school. Weekends, vacation and all summer including summer school. School sponsored and extracurricular sports excluding High School Football.

$112.00 $165.00
24-Hour Accident (Summer Only Coverage)
Summer begins on the first day after the school year ends.
Summer ends the first day of the next school year.
$39.00 $51.00
At-School Accident
During the regular school term, on school premises while school is in session. Direct and uninterrupted travel to and from home and scheduled classes. School Sponsored and supervised activities and sports excluding High School Football. Travel to and from school sponsored and supervised activities and sports while in a school furnished or approved vehicle.
$30.00 $38.00
High School Football (Full Year)
Play or practice of regularly scheduled football.
$176.00 $293.00
High School Football (Spring Only Rates)
For new players who participate in spring training and not already insured under Football Coverage. Sports seasons are defined by your state high school athletic association.
$76.00 $124.00
High School Football and At-School Accident (Covers all athletics) $206.00 $331.00
High School Football and 24-Hour Accident (Covers all athletics) $288.00 $458.00

About Your Coverage

  1. ELIGIBLE PERSONS: students of the policyholder who enroll and make the required premium contribution for the coverage selected are Eligible Persons under the Policy. Depending on the coverage selected, coverage may continue after graduation and between school years unless the person enrolls at a different school district.
  2. The Master Policy is on file with the school district and is a non-renewable policy. The student coverage selected is non-renewable and requires the student to re-enroll each school year.
  3. This is a limited benefit policy.
  4. COVERAGE EFFECTIVE DATE: Insurance becomes effective for a student who enrolls and makes the required premium contribution on the latest of the following dates:
    1. the Policy Effective Date;
    2. the date the Company receives student’s completed enrollment form and the required premium payment. In no event will insurance for the Eligible Person become effective before the Policy Effective Date.
  5. COVERAGE TERMINATION DATE: Coverage ends on the earlier of the date: he or she is no longer an Eligible Person, the end of the 1 year coverage term or the date the School’s policy ends. All coverage ceases if the policyholder cancels the policy or when person ceases to be eligible. Termination of coverage for any reason will not affect a claim for a Covered Accident that occurs before the termination date.
  6. LATE ENROLLMENT: Coverage may be purchased at any time during the school year. There is no premium reduction for any individual who enrolls late in the year.
  7. CANCELLATION: Your coverage under the Policy will not be cancelled, and accordingly, premiums may not be refunded after acceptance by the Company.

Enroll online at: www.StudentInsurance-kk.com or by mail using attached enrollment form.

  1. Complete and detach the enrollment form.
  2. Make check or money order payable to Axis Insurance Company. Do not send cash. The Company is not responsible for cash payments.
  3. Write your child’s name on your check or money order.
  4. Mail completed enrollment form with payment back to:
    • K&K Insurance Group,
    • P.O. Box 2338
    • Fort Wayne, IN 46801-2338
  5. Your cancelled check, credit card billing, or money order stub will be your receipt and confirmation of payment.
  6. Keep this brochure for future reference. Individual policies will not be sent to you.

Privacy Policy
We know that your privacy is important to you and we strive to protect the confidentiality of your nonpublic personal information. We do not disclose any nonpublic personal information about our customers or former customers to anyone, except as permitted or required by law. We believe
we maintain appropriate physical, electronic and procedural safeguards to ensure the security of your nonpublic personal information. 

Administered by:
K&K Insurance Group, P.O. Box 2338,
Fort Wayne, IN 46801-2338

COMMON EXCLUSIONS
In addition to any benefit or coverage specific exclusion, benefits will not be paid for any loss which directly or indirectly, in whole or in part, is caused by or results from any of the following unless
coverage is specifically provided for by name in the Description of Benefits Section or Conditions of Coverage Section:

  1. intentionally self-inflicted injury, suicide, or any attempt while sane or insane; 
  2. commission or attempt to commit a felony or an assault;
  3. commission of or active participation in a riot or insurrection;
  4. declared or undeclared war or act of war or any act of declared or undeclared war unless specifically provided by this Policy;
  5. flight in, boarding or alighting from an Aircraft, except as a passenger on a regularly scheduled commercial airline;
  6. travel in any Aircraft owned, leased operated or controlled by the Policyholder, or any of its subsidiaries or affiliates. An Aircraft will be deemed to be “controlled” by the Policyholder if the Aircraft may be used as the Policyholder wishes for more than 10 straight days, or more than 15 days in any year;
  7. sickness, disease, bodily or mental infirmity, bacterial or viral infection or medical or surgical treatment thereof, (including exposure, whether or not Accidental, to viral, bacterial or chemical agents) whether the loss results directly or non directly from the treatment except for any bacterial infection resulting from an Accidental external cut or wound or Accidental ingestion of contaminated food;
  8. voluntary ingestion of any narcotic, drug, poison, gas or fumes, unless prescribed or taken under the direction of a Physician and taken in accordance with the prescribed dosage;
  9. injuries compensable under Workers’ Compensation law or any similar law;
  10. operating any type of vehicle or Conveyance while under the influence of alcohol or any drug, narcotic or other intoxicant including any prescribed drug for which the Insured Person has been provided a written warning against operating a vehicle or Conveyance while taking it. Under the influence of alcohol, for purposes of this exclusion, means intoxicated, as defined by the motor vehicle laws of the state in which the Covered Loss occurred;
  11. the Insured Person’s intoxication. The Insured Person is conclusively deemed to be intoxicated if the level in His blood exceeds the amount at which a person is presumed, under the law of the locale in which the accident occurred, to be under the influence of alcohol if operating a motor vehicle, regardless of whether He is in fact operating a motor vehicle, when the injury occurs. An autopsy report from a licensed medical examiner, law enforcement officer’s report, or similar items will be considered proof of the Insured Person’s intoxication;
  12. an Accident if the Insured Person is the operator of a motor vehicle and does not possess a valid motor vehicle operator’s license, unless: (a) the Insured Person holds a valid learners permit and (b) the Insured Person is receiving instruction from a driver’s education instructor;
  13. aggravation, during a Covered Activity, of an injury the Insured Person suffered before participating in that Covered Activity unless the Company receives a written medical release from the Insured Person’s Physician;
  14. participating in any hazardous activities, including the sports of snowmobile, ATV (all terrain or similar type wheeled vehicle), personal watercraft, sky diving, scuba diving, skin diving, hang gliding, cave exploration, bungee jumping, parachute jumping or mountain climbing;
  15. medical or surgical treatment, diagnostic procedure, administration of anesthesia, or medical mishap or negligence, including malpractice unless it occurs during treatment of a Covered Injury; or 
  16. benefits will not be paid for services or treatment rendered by any person who is:
    • employed or retained by the Policyholder;
    • living in the Insured Person’s household;
    • an Immediate Family Member, including domestic partner, of either the Insured Person or the Insured Person’s Spouse; or
    • the Insured Person.

EXCLUDED EXPENSES
The following will not be considered Medically Necessary Covered Expenses unless coverage is specifically provided:

  1. cosmetic surgery, except for reconstructive surgery needed as the result of a Covered Injury;
  2. any elective or routine treatment, surgery, health treatment, or examination, including any service, treatment of supplies that: (a) are deemed by the Company to be experimental or investigational; and (b) are not recognized and generally accepted medical practice in the United States;
  3. examination or prescriptions for, or purchase, repair or replacement of wheelchairs, braces, appliances, orthopedic braces, or orthotic devices;
  4. treatment in any Veteran’s Administration, Federal, or state facility, unless there is a legal obligation to pay;
  5. services or treatment provided by persons who do not normally charge for their services, unless there is a legal obligation to pay;
  6. repair or replacement of existing artificial limbs, eyes and larynx;
  7. treatment of an injury resulting from a condition that the Insured Person knew existed on the date of a Covered Accident, unless the Company has received a written medical release from his Physician. In no event will the Company’s total payments for the Insured Person exceed the Total Maximum for all Accident Medical Benefits shown in the Schedule of Benefits. Other Exclusions that apply to this Benefit are in the Common Exclusions Section.

ACCIDENT ONLY DEFINITIONS:

Covered Injury means Accidental bodily injury:

  1. which is sustained by an Insured Person as a direct result of an unintended, unanticipated Covered Accident that is external to the body and that occurs while the injured person’s coverage under the Policy is in force;
  2. which results directly and independently from all other causes from a Covered Accident; and
  3. which occurs while such person is participating in a Covered Activity. The Covered Injury must be caused through Accidental means. All injuries sustained by an Insured Person in any one Covered Accident, including related conditions and recurrent symptoms of these injuries, are considered a single injury. 

Accident or Accidental: means a sudden, unexpected, specific and abrupt event that occurs by chance at an identifiable time and place while the Insured Person is covered under this Policy. 

Covered Expenses: means expenses actually incurred by or on behalf of an Insured Person for treatment, services and supplies covered by this Policy. A Covered Expense is deemed to be incurred on the date treatment, service or supply that gave rise to the expense or the charge, was rendered or obtained.

Medically Necessary: means medical services that:

  1. are essential for diagnosis, treatment or care of the Covered Injury for which it is prescribed or performed;
  2. meets generally accepted standards of medical practice; and
  3. are ordered by a Physician and performed under His care, supervision or order.

ACCIDENTAL DEATH AND DISMEMBERMENT BENEFITS:

Covered Loss must occur within 365 days of the Covered Accident. Not more than the Aggregate Limit of $500,000 will be paid for all Covered Losses, Covered Accidents and Covered Injuries suffered by all Insured Persons as the result of any one Covered Accident that occurs under one of the Conditions of Coverage. This Aggregate Limit is payable only once, should more than one Condition of Coverage apply, We will pay the greater amount. If this amount does not allow all Insured Persons to be paid the amounts this Policy otherwise provides, the amount paid will be the proportion of the Insured Person’s loss to the total of all losses, multiplied by the Aggregate Limit.

COVERED LOSS BENEFIT AMOUNT
Loss of Life $10,000
Loss of Two or More Hands or Feet $10,000
Loss of Sight of Both Eyes $10,000
Loss of Speech and Hearing (in Both Ears) $10,000
Loss of One Hand or Foot and Sight in One Eye $10,000
Loss of One Hand or Foot $5,000
Loss of Sight in One Eye $5,000
Loss of Speech $5,000
Loss of Hearing (in Both Ears) $5,000
Loss of Hearing in One Ear $2,500
Loss of Thumb and Index Finger of the same Hand $2,500
Exposure and Disappearance Included

Please download the form to fill out and return if you need.

IMPORTANT NOTICE - FRAUD WARNING

In General, and specifically for residents of Arkansas, Illinois, Louisiana, Rhode Island and West Virginia: Any person who knowingly presents a false or fraudulent claim for payment of a loss or benefit or knowingly presents false information in an application for insurance is guilty of a crime and may be subject to fines and confinement in prison.

  • For residents of Alabama: Any person who knowingly presents a false or fraudulent claim for payment of a loss or benefit or knowingly presents false information in an application for insurance is guilty of a crime and may be subject to restitution fines and confinement in prison, or any combination thereof.
  • For residents of Colorado: It is unlawful to knowingly provide false, incomplete, or misleading facts or information to an insurance company for the purpose of defrauding or attempting to defraud the company. Penalties may include imprisonment, fines, denial of insurance, and civil damages. Any insurance company or agent of an insurance company who knowingly provides false, incomplete, or misleading facts or information to a policyholder or claimant for the purpose of defrauding or attempting to defraud the policyholder or claimant with regard to a settlement or award payable from insurance proceeds shall be reported to the Colorado division of insurance within the department of regulatory agencies.
  • For residents of the District of Columbia: WARNING: It is a crime to provide false or misleading information to an insurer for the purpose of defrauding the insurer or any other person. Penalties include imprisonment and/or fines. In addition, an insurer may deny insurance benefits if false information materially related to a claim was provided by the applicant.
  • For residents of Florida: Any person who knowingly and with intent to injure, defraud, or deceive any insurer files a statement of claim or an application containing any false, incomplete, or misleading information is guilty of a felony of the third degree.
  • For residents of Kentucky: Any person who knowingly and with intent to defraud any insurance company or other person files an application for insurance containing any materially false information or conceals, for the purpose of misleading, information concerning any fact material thereto commits a fraudulent insurance act, which is a crime.
  • For residents of Maine, Tennessee and Washington: It is a crime to knowingly provide false, incomplete or misleading information to an insurance company for the purpose of defrauding the company. Penalties include imprisonment, fines and denial of insurance benefits.
  • For residents of Oregon: Any person who knowingly and willfully presents a false or fraudulent claim for payment of a loss or benefit or who knowingly or willfully presents false information in an application for insurance may be guilty of a crime and may be subject to fines and confinement in prison.
  • For residents of Maryland: Any person who knowingly or willfully presents a false or fraudulent claim for payment of a loss or benefit or who knowingly or willfully presents false information in an application for insurance is guilty of a crime and may be subject to fines and confinement in prison.
  • For residents of New Jersey: Any person who includes any false or misleading information on an application for an insurance policy is subject to criminal and civil penalties.
  • For residents of New Mexico: ANY PERSON WHO KNOWINGLY PRESENTS A FALSE OR FRAUDULENT CLAIM FOR PAYMENT OF A LOSS OR BENEFIT OR KNOWINGLY PRESENTS FALSE INFORMATION IN AN APPLICATION FOR INSURANCE IS GUILTY OF A CRIME AND MAY BE SUBJECT TO CIVIL FINES AND CRIMINAL PENALTIES.
  • For residents of New York: Any person who knowingly and with intent to defraud any insurance company or other person files an application for insurance or statement of claim containing any materially false information, or conceals for the purpose of misleading, information concerning any fact material thereto, commits a fraudulent insurance act, which is a crime, and shall also be subject to a civil penalty not to exceed five thousand dollars and the stated value of the claim for each such violation.
  • For residents of Ohio: Any person who, with intent to defraud or knowing that he is facilitating a fraud against an insurer, submits an application or files a claim containing a false or deceptive statement is guilty of insurance fraud.
  • For residents of Oklahoma: WARNING: Any person who knowingly, and with intent to injure, defraud or deceive any insurer, makes any claim for the proceeds of an insurance policy containing any false, incomplete or misleading information is guilty of a felony.
  • For residents of Pennsylvania: Any person who knowingly and with intent to defraud any insurance company or other person files an application for insurance or statement of claim containing any materially false information or conceals for the purpose of misleading, information concerning any fact material thereto commits a fraudulent insurance act, which is a crime and subjects such person to criminal and civil penalties.
  • For residents of Texas: Any person who knowingly presents a false or fraudulent claim for the payment of a loss is guilty of a crime and may be subject to fines and confinement in state prison.
  • For residents of Virginia: Any person who with the intent to defraud or knowing that he is facilitating a fraud against an insurer submits an application or files a false or deceptive statement may have violated state law.

[ AXIS_FRAUD 0221 ]

K-12 Student Accident Insurance

Enroll Online

Worried about paying for your child's medical care if an accident should happen?  K&K's student accident insurance can help.

K-12 Accident Plans available through your school:

  • At-School Accident Only
  • 24-Hour Accident Only
  • Extended Dental
  • Football

How to Enroll Online

Enrolling online is easy and should take only a few minutes.  Go to www.studentinsurance-kk.com and click the "Enroll Now" button.

  1. Start by telling us the name of the school district and state where your child attends school.
  2. We'll request each student's name and grade level.
  3. You'll see the available plans and their rates.  Select your coverage and continue to the next step.
  4. We'll request information about you, like your name and email address.
  5. Next, you'll enter information about the child or children to be covered.
  6. Enter your credit card or eCheck payment information
  7. Finally, print out a copy of the confirmation for your records.

For further details of the coverage including costs, benefits, exclusions, any reductions or limitations and terms under which the policy may be continued in form, please refer to www.studentinsurance-kk.com.  Student is able to purchase the coverage only if his/her school district is a policyholder with the insurance company.

Student/Athlete & Parent/Legal Guardian Signature Booklet

Office Use Only - Do Not Write in This Area

  • Football
  • Volleyball
  • Cross Country
  • Wrestling
  • Boys Basketball
  • Girls Basketball
  • Track
  • Speech and Debate
  • Science Olympiad
  • Builder's Club
  • Drama Club
  • Manager (Name Event)
  • Other Club(s)

By signing below, you agree to the policies stated in the Activities Participation Booklet and adhere to its Chemical Use Policy during your season of participation.

I have read and understand the activities policy included in this booklet.

  • Parent/Guardian Signature
  • Date
  • Participant Signature
  • Sport

Belgrade Public Schools (School District #44) will not discriminate on the basis of sex, race, marital status, national origin, or disability in our educational programs or in our activities. All students will be treated equally.

BELGRADE SCHOOL ATHLETICS INFORMED CONSENT AND INSURANCE VERIFICATION FORM

Extracurricular activities may include physical contact and physical exertion. There is an inherent risk of injury in the activity. By signing this agreement, I acknowledge that the School District staff try to prevent accidents. I agree to accept responsibility for my student’s participation in school activities. The activity is strictly voluntary.

I, the undersigned, hereby acknowledge and understand that, regardless of all feasible safety measures that may be taken by the School District, participation in this event entails certain inherent risks. I certify that my student is physically fit and medically able to participate or have noted an applicable physical or medical diagnosis at the bottom of this form. I further certify that my student will honor all instructions of district staff and failure to honor instructions may result in dismissal from the activity. I have been informed of these risks, understand them, and feel that the benefits of participation outweigh the risks involved. My signature below gives my child permission to participate in a ____School Activity.

I authorize qualified emergency medical professionals to examine and in the event of injury or serious illness, administer emergency care to my student. I understand every effort will be made to contact the family or contact person noted below to explain the nature of the problem prior to any involved treatment. In the event it becomes necessary for the district staff in charge to obtain emergency care for my student, I understand that neither the district employee in charge of the activity nor the school district assumes financial liability for expenses incurred because of an accident, injury, illness and/or unforeseen circumstances.

The School District DOES NOT provide medical insurance benefits for students who choose to participate in activities programs. If parents or guardians have their own insurance coverage during the student’s participation, that coverage information is provided below.

  • I have personal medical insurance to cover the student’s participation:
    • INSURANCE (Company Name)  
    • Policy # 
  • I do not have personal medical insurance to cover the student’s participation and understand that the School District does not provide medical insurance to cover the students. I understand I will be responsible for any medical costs associated with the student’s participation.

Signature Required Regardless of Insurance Coverage:

  • Student Athlete (Please Print)
  • Parent/Guardian (Signature)
  • Date:

Student-Athlete & Parent/Legal Guardian Concussion Statement

Because of the passage of the Dylan Steiger’s Protection of Youth Athletes Act, schools are required to distribute information sheets for the purpose of informing and educating student-athletes and their parents of the nature and risk of concussion and head injury to student athletes, including the risks of continuing to play after concussion or head injury. Montana law requires that each year, before beginning practice for an organized activity, a student-athlete and the student-athlete’s parent(s)/legal guardian(s) must be given an information sheet, and both parties must sign and return a form acknowledging receipt of the information to an official designated by the school or school district prior to the student-athletes participation during the designated school year. The law further states that a student-athlete who is suspected of sustaining a concussion or head injury in a practice or game shall be removed from play at the time of injury and may not return to play until the student-athlete has received a written clearance from a licensed health-care provider.

Student-Athlete Name:

  • This form must be completed for each student-athlete, even if there are multiple student-athletes in each household.
  • Parent/Legal Guardian Name(s):                                                                                       
  • We have read the Student-Athlete & Parent/Legal Guardian Concussion Information Sheet.
    • If true, please check box

MEDICAL TREATMENT/RELEASE FORM

To: Parents and/or Guardians of Students Representing School District No. 44 in Activity Programs.

It has become exceedingly difficult to obtain medical services for students injured when competing, without first obtaining parental/guardian consent in writing. So that proper emergency assistance may be provided, we ask that you review the following statement, Sign and return to the faculty member in charge.

I hereby authorize School District No. 44 and its faculty members in charge of my child named below to obtain all necessary medical care for my child and I hereby authorize  Any licensed physician and/or medical personnel to render necessary medical treatment to my child.

  • Print Student’s Name
    • Signed (Parent and/or Guardian)
    • Address
    • Telephone No. 
    • Date: 
  • Emergency Contact (Within 15 miles of Belgrade)
    • Name:
    • Address: 
    • Telephone No.
    • Relationship to Student:
  • Allergies?
    • YES
    • NO
  • Medication Needed
    • YES
    • NO
  • Special Medical Problems?
    • YES
    • NO