Mandated Reporter Volunteer and Chaperone Forms

Lowndes County Schools Volunteer Procedures:

Definition of a Volunteer:

Volunteer - Anyone providing supervision while actively interacting with students, or anyone having responsibility of students of Lowndes County Schools (LCS). The period of supervision also includes activities outside the normal school day such as field trips, athletic events. etc.

Requirements of volunteers before they are allowed to interact with students:

A. Watch the DOE Mandated Reporter Power Point (PPT).

B. Consent to local background check. Principal will be notified if an issue is identified on the                                                                                  
    background check.

C. Sign the volunteer statement indicating the PPT has been viewed and that the school protocol

    and mandated reporting law is understood.

Identification of volunteers after completing the requirements:

A.  Volunteers will show a photo id before performing volunteer activities.

B.  Schools will designate a certified staff member to maintain the signed statements.  

Statement Requiring Volunteer Signature:

Lowndes County Schools Volunteer Statement


After receiving training, I confirm the following:

  1. I have watched a Mandated Reporter training PPT provided by LCS.

  1. I understand that it is law that I must report immediately any suspected abuse.  Reports are made to a school administrator or counselor as this is LCS policy.  I understand it is a crime if I do not report suspected abuse.

  1. I understand when I make a report or cause a report to be made, mandated reporters only need to have “reasonable suspicions” not direct evidence.

  1. I understand it is against the law for any mandated reporter to notify the parent that a referral has been made.  It is the policy of the Department of Family and Children Services (DFACS) that Child Protective Services notify the parent upon investigation.

  1. I understand that my responsibility is to report any suspected abuse and not investigate the matter. Investigations will be conducted by school officials, DFACS, Child Protective Services, and law enforcement. I will not conduct an investigation, and will not interrogate a child for any reason.

  1. I will keep all matters confidential. This is a legal mandate as well as something I would demand if the situation involved my family. These children deserve the same privacy.

Volunteer Signature:  ______________________________________________

School Designee Signature: _________________________________________

Date:  _______________________

Lowndes County Sheriff’s Office

Criminal History Search

Consent Form

I hereby authorize the Lowndes County Board of Education to receive any Georgia criminal history record information pertaining to me, which may be in the files of any state or local Criminal Justice Agency. Results may be released to Lowndes County Schools – Human Resources Department.


Full Name – Printed


Address                                              City              State                  Zip Code

____ ____ ___________ _________________

Sex Race Date of Birth Social Security Number


Signature            Date


Contact number(s)

Special employment provisions (check if applicable):

☐ Employment with mentally disabled (Purpose Code ‘M’)

☐ Employment with elder care (Purpose Code ‘N’)

      MCWB01114_0000[1] Employment with children (Purpose Code ‘W’)

Notary Public, Lowndes County, GA

My commission expires ___________________


Notary Signature

Volunteer’s Personal Affirmation

Volunteer’s Name: __________________________________________________________________________________

          Please Print Last Name, First Name and Middle Initial

Address: _______________________________________________________________________________________________

Contact Numbers: __________________________________________ ___________________________________

    Home/Cellular       Work

Instructions:  The Volunteer must enter a "Yes" or "No" response to each of the following questions.  All questions must have a response (please circle your responses) in order for the volunteer process to continue.  Please attach an explanation for any "YES" response.

  1. Yes      No    Are you the subject of a pending investigation involving a criminal act?

  1. Yes      No    Are you currently the subject of an investigation involving sexual misconduct                       or physical/psychological harm to a child?

  1. Yes      No    For any misdemeanor and/or felony criminal offense, have you ever:

        Please circle the applicable response(s).

♦ Pled guilty;

♦ Entered a plea of nolo contendere;

♦ Entered an Alford plea;

♦ Been found guilty;

♦ Pled guilty to a lesser offense;

♦ Been granted first offender treatment without adjudication of guilt;

♦ Participated in a pre-trial diversion program;

♦ Been found not guilty by reason of insanity; or

♦ Been placed under a court order whereby an adjudication or sentence was withheld?

  1. Yes      No    Have you ever been convicted or pled to a lesser offense for any sexual                       offense?

  1. Yes      No    Have you been convicted of a drug offense (felony or misdemeanor)?

  1. Yes      No    Have you been convicted of a crime of violence (felony or misdemeanor)?


I affirm that my responses are true and correct. I hereby give permission to Lowndes County Schools to obtain copies of any criminal records relating to me which are held by any local, state or federal government agency. I authorize any such agency or entity to release those records to Lowndes County Schools.  

Signature: __________________________________ Date: ________________________

NOTE: This Volunteer’s Personal Affirmation must be completed, signed, dated, received by the school principal and approved by the system before the volunteer activity begins. This Volunteer’s Personal Affirmation will be valid for the current school year.  A new Volunteer’s Personal Affirmation will be required for each subsequent school year. Thank you for your cooperation in this matter of mutual concern.