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Survivor Connection
The Philadelphia Center for Gun Violence Reporting
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Survivor Connection
The Philadelphia Center for Gun Violence Reporting
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Create Your Profile
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Create Your Profile
1
Basic Info
2
Your Story
3
Availability
Your Name
(Required)
First
Last
Preferred name, if different
Organization, if applicable
Phone
(Required)
Email
(Required)
What has been your experience? Please select all that apply.
(Required)
Survivor: I have been wounded by gunfire.
Co-survivor: Someone I love has been wounded or killed.
Community expert: Gun violence has impacted me and/or my community.
Prevention advocate: My work includes gun violence prevention. No college degree required.
Other: Please explain below.
If you selected "Other," please explain here:
(Required)
Year of primary incident, if applicable
Age of primary survivor at time of incident, if applicable
Do you live in Philadelphia now?
(Required)
-- Select --
Yes
No
If yes, what section of the city do you live in?
If yes, what is the ZIP Code where you live?
(Required)
What role do you play now?
(Required)
I lead or work in a violence prevention initiative or organization.
I volunteer to make things better in my neighborhood.
I help survivors cope with their injuries.
I help keep kids out of trouble.
I volunteer to help survivors at a hospital.
I speak at events and/or in the media.
I participate in media reports and/or press conferences.
I advocate for victims on social media.
I organize events to help survivors.
I participate in research.
Other
If you selected "Other," please explain here:
(Required)
This field is hidden when viewing the form
Your story
Describe what you experienced, biographical details, and anything else you want to share with journalists.
Availability
I am available for interviews. Choose one option
(Required)
On the record, including my name and my face
On the record, including my name but not my face
On the record, including my face but not my name
Off the record only
Not available at this time
I am open to these types of interviews. Select all that apply.
(Required)
TV (live)
TV (recorded)
Audio (live)
Audio (recorded)
None of the above
Type of media. Select all that apply.
(Required)
Web
Print
Photo
None of the above
Days I am available
(Required)
-- Select --
Any day
Weekdays only
Weekends only
Best time to contact me
(Required)
-- Select --
Mornings (6am - 12pm)
Afternoons (12pm - 6pm)
Evenings (6pm - 12am)
Anytime
Best way to contact me
(Required)
-- Select --
Call
Text
Email
Upload a Photo:
Max. file size: 128 MB.
Suggestion: Share a photo that captures your strength and resilience—one that represents how you've turned your experience into a positive force for change and leadership.
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