New Member Intake Form & Application — 100 Days in Appalachia

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First Name

Last Name

We want to pronounce your name correctly, so please write out your own name phonetically here:

Please share your racial identity. (For example: mixed race, white, Asian; etc., or prefer not to say.)

Please share your gender identity. (For example: female; nonbinary; etc. or prefer not to say.)

Please share the pronouns you use. (For example: she/her; he/him; they/them; etc.) And if your pronouns change, you can update them with us at any time.

Location (City, State)

Please share any accessibility needs you have, so we can best accommodate you.

To communicate with the cohort, our team primarily uses Protonmail to send cohort updates, polls and other vital information. Please create an email at https://proton.me if you have not yet done so, and provide it here:

We also use Signal to communicate, and have a Signal group message with all cohort members. Please review the Terms of Engagement* to be admitted in the group.

I have read and understand the terms of engagement for the Signal group

Terms of Engagement can be found here: https://drive.proton.me/urls/B0XJ2M6MGR#pfR6Uj0jbwyW

If you have reviewed the Terms of Engagement, please provide your Signal phone number.

About your work

Newsroom (include link if applicable):

Title and Beat:

Please submit your preferred bio for this group here:

Please upload your headshot.

Click or drag a file to this area to upload.

Please upload a signed copy of your w-9 for us to have on file.

Click or drag a file to this area to upload.

About your expertise.

This program is intended to convene reporters at different levels of experience in this topic, whether beginner or established. Please provide a self-assessment of your current experience or knowledge level in order to best shape the curriculum.

Understanding the History of Domestic Extremism

Selected Value: 1

Understanding of Recent On and Offline Tactics of Radicalization

Selected Value: 0

Digital Forensic Investigation Techniques

Selected Value: 0

Public Records Searches

Selected Value: 0

Digital Safety

Selected Value: 0

Physical Safety in Hostile Environments

Selected Value: 0

Ethical Issues in Documenting Hate and Extremism

Selected Value: 0

Engaged Journalism Practices

Selected Value: 0

Please link to previous extremism or extremism-adjacent reporting. If you have not published, but have a work in progress, indicate where you are in that process.

This program is explicitly designed to build an enduring community of practice with long term local impact. Ideally, selected participants will continue to participate in peer support and mentorship.

Are you willing to mentor other reporters in your region after the completion of this workshop series

How much time could you commit to peer support and mentoring others?

Tell us why you are interested in this workshop series and what you hope to gain from it professionally/personally (up to 650 words).

Have you attended any other training activities related to covering extremism, digital safety and security, and/or Hostile Environment and First Aid (HEFAT) in the past three years?

If you answered yes above, please list the workshop, provider and date completed.

What do you feel like you can best contribute to this community of practice? (up to 300 words)

Please share any concerns or special requests you have.

Reporting on Extremism Cohort Commitments

If I am selected to be a member of this cohort, I commit to attending at least one cohort convening per year; sharing my experiences and perspectives and listening to those of others in the spirit of building bonds of trust and affection; and utilizing my knowledge and network to benefit the collective power of this cohort.

Yes, I make this commitment.

This is a private, invite-only, off-the-record community, and this invitation and application is non-transferable. For the safety and security of all participants, I commit to not disclose details of this application, cohort and all correspondence shared with me prior to and following acceptance into the cohort, unless permission is otherwise granted from the program team.

Yes, I make this commitment.