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DARE TO BE DIFFERENTExternal link opens in new tab or window

YOUTH EMPOWERMENT ORGANIZATION

Creating A Knock-On Effect For Youth Confidence

External link opens in new tab or window(352) 665-4551(352) 665-4551
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Registration Form

First Step to Registration Submitting the form below will begin the registration process for your child to become an official member of dare to be different empowerment organization. You will receive a welcome email within 3 business days with more information on programming and next steps. THIS IS CRUCIAL so please check your inbox or spam folders. If you should have any questions, feel free to contact us. Registration Form must be completed by a parent/guardian.


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Mentee Name *
Grade *

Date of Birth *

Parent/ or Guardian *

Address *

Email address *

Emergency contact *


Consent Statement (A) By checking "Yes" as the parent/guardian of the above named child, I do herby give consent for my child to become member of dare to be different youth employment.

Yes * 
 No * 

Dare to be different youth empowerment often offer food and minor physical activities. Please list any health concerns, restrictions, medications or allergies if applicable.



Please  list any areas of concern,  in which your child may need support from dare to be different empowerment.



T-shirt size


Consent statement (B) By checking " Yes" as the parent/guardian of the above named child, I give consent to dare to be different empowerment to use my child's photo or likeness for promotional usage. (i.e. websites, social media, merchandise, banners, flyer etc.)

Yes * 
 No * 




Hygiene Pantry Program

Toiletries Requested*
Please select which items your household would like donated.

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Soap
Lotion
Toothbrush
Toothpaste
Mouthwash
 Deodorant
Shampoo
Conditioner
Sanitary Napkins
Tampons
Cleaning Cloths Wipes


Household Size *
Contact Person *
Contact Email *
Contact Phone *
Complete Address *




Dare To Be Different Youth Empowerment Organization

Dare To Be Different Youth Empowerment Organization


 Gainesville, FL

Email: info@daretobedifferentempowerment.org

Phone: External link opens in new tab or window(352) 665-4551

Column

Hours of Operation


 Monday to Friday: 9:00 AM – 5:00 PM
Saturday to Sunday: Closed

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Service Areas


 Florida

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