Butterfly Kit, Licensing Fee, & Film Screening Order Form Step 1 of 2 50% This order form is for all US orders of butterfly kits and film licensing fees. If you are submitting an order for a German school or community, please click here. If you are not from the US or Germany, please email us directly to inquiry about purchasing a kit or film licensing fee.Participant InformationPlease provide the name of the school, organization, or family that will use the kit(s) or view the film.*Please provide the name of the person facilitating or hosting the butterfly event. First Last Please provide the email of the person facilitating or hosting the butterfly event. What date do you need your butterfly kit(s) and/or film?* Who are these butterfly kit(s) and/or film screening for?*School/ClassroomCommunity EventLibrary/MuseumJCCBar/Bat MitzvahSynagogueChurchFamily EventPlease tell us why you are bringing The Butterfly Project into your classroom or community (select all that apply):* I want to increase the culture of respect and inclusion in my classroom/community. I want to help my students/community members to recognize and interrupt bullying sooner. I want my students/community members to get more in-depth age-appropriate education about the Holocaust. Teaching the topic of the Holocaust is challenging. Making a personal connection to stories through a Holocaust speaker will assist in student understanding. Making an installation of butterflies is a priority and helps students/community members remember and identify with this topic. I would like to learn more about showing the film NOT The Last Butterfly at my school. What educational components you will be using in at your event?*Please provide the date and information about the event.*How did you hear about The Butterfly Project?*Is this your first time participating in The Butterfly Project?*YesNoNot sureAre you a Title I school?*YesNoNot sureAre you based in San Diego?*YesNoThe Butterfly Project is fortunate to be able to offer San Diego County-based schools and community organizations the opportunity for classroom visits from our Education Team, which is comprised of retired educators and Second Generation members (whose parents were Holocaust survivors). Our Education Team's presentation consists of age-appropriate lessons on anti-bullying, prejudice, discrimination, and teaches students what it means to be an Upstander. For grades 6 and above, the Education Team also discusses what led to the Holocaust. Woven into the presentation are the Education Team's personal family stories, photos, and primary source artifacts. Emphasis is placed on "The Power of One"--examples of UPSTANDERS (vs. Bystanders) those who made a difference during the Holocaust by standing up against persecution and relating that theme to our responsibility in today's world to do the same.Would you like to learn more about bringing our Education Team to your classroom?*YesNoI am already in contact with the Education Team about a classroom visit. Our kits include materials for 36 individuals to participate, including 36 ceramic butterflies, 36 biography cards, 36 paint brushes, and glazes for 36 participants. Butterfly Kits If you are making your own butterflies or hosting a large community event, please include the licensing fee in your order. Thanks to generous support from our donors, we are able to waive the licensing fee for schools and small community organizations, and offer a subsidized rate for our butterfly kits. If you are a teacher or school administrator, please select the Educator rate. These rates are reserved for teachers and other school administrators. If you are in the San Diego area and available to pick up kit(s) from our office, you do not need to pay for shipping. If the Education Team will be visiting your school or organization, they will bring the kit with them.Butterfly Kit (Educator Rate) Price: $72.00 Quantity: Butterfly Kit (Non-Educator Rate) Price: $180.00 Quantity: Additional Glaze Strips Price: $1.50 Quantity: Licensing Fee Price: $75.00 Quantity: If you are making your own butterflies or hosting a large community event, please include the licensing fee in your order. Due to the generous support of our donors, we are able to waive the licensing fee for schools and small community organizations.Please tell us how you will receive your kits.*I will need my kit(s) shipped to me.I will pick my kit(s) up from the office in San Diego.Someone from The Butterfly Project is attending my event and will bring my kit(s) to our school/venue.I am not ordering kits.Shipping Fees per Kit (please enter the TOTAL number of kits that you are ordering) Price: $22.95 Quantity: Film Screening Fees Thanks to generous funding from our donors, we are able to subsidize the film licensing fee for educators. If you are a teacher or school administrator, please select the Educator rate. These rates are reserved for teachers and other school administrators.Film Screening Fee (Educator Rate) Price: $180.00 Quantity: Film Screening Fee Price: $360.00 Quantity: Total $0.00 Purchaser InformationName* First Last Email* Phone* Shipping Address:* Street Address Address Line 2 City State / Province / Region ZIP / Postal Code AfghanistanAlbaniaAlgeriaAmerican SamoaAndorraAngolaAnguillaAntarcticaAntigua and BarbudaArgentinaArmeniaArubaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBoliviaBonaire, Sint Eustatius and SabaBosnia and HerzegovinaBotswanaBouvet IslandBrazilBritish Indian Ocean TerritoryBrunei DarussalamBulgariaBurkina FasoBurundiCambodiaCameroonCanadaCape VerdeCayman IslandsCentral African RepublicChadChileChinaChristmas IslandCocos IslandsColombiaComorosCongo, Democratic Republic of theCongo, Republic of theCook IslandsCosta RicaCroatiaCubaCuraçaoCyprusCzech RepublicCôte d'IvoireDenmarkDjiboutiDominicaDominican RepublicEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEswatini (Swaziland)EthiopiaFalkland IslandsFaroe IslandsFijiFinlandFranceFrench GuianaFrench PolynesiaFrench Southern TerritoriesGabonGambiaGeorgiaGermanyGhanaGibraltarGreeceGreenlandGrenadaGuadeloupeGuamGuatemalaGuernseyGuineaGuinea-BissauGuyanaHaitiHeard and McDonald IslandsHoly SeeHondurasHong KongHungaryIcelandIndiaIndonesiaIranIraqIrelandIsle of ManIsraelItalyJamaicaJapanJerseyJordanKazakhstanKenyaKiribatiKuwaitKyrgyzstanLao People's Democratic RepublicLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacauMacedoniaMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMartiniqueMauritaniaMauritiusMayotteMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMontserratMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew CaledoniaNew ZealandNicaraguaNigerNigeriaNiueNorfolk IslandNorth KoreaNorthern Mariana IslandsNorwayOmanPakistanPalauPalestine, State ofPanamaPapua New GuineaParaguayPeruPhilippinesPitcairnPolandPortugalPuerto RicoQatarRomaniaRussiaRwandaRéunionSaint BarthélemySaint HelenaSaint Kitts and NevisSaint LuciaSaint MartinSaint Pierre and MiquelonSaint Vincent and the GrenadinesSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSint MaartenSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSouth GeorgiaSouth KoreaSouth SudanSpainSri LankaSudanSurinameSvalbard and Jan Mayen IslandsSwedenSwitzerlandSyriaTaiwanTajikistanTanzaniaThailandTimor-LesteTogoTokelauTongaTrinidad and TobagoTunisiaTurkeyTurkmenistanTurks and Caicos IslandsTuvaluUS Minor Outlying IslandsUgandaUkraineUnited Arab EmiratesUnited KingdomUnited StatesUruguayUzbekistanVanuatuVenezuelaVietnamVirgin Islands, BritishVirgin Islands, U.S.Wallis and FutunaWestern SaharaYemenZambiaZimbabweÅland Islands Country Billing Address (if different): Street Address Address Line 2 City State / Province / Region ZIP / Postal Code AfghanistanAlbaniaAlgeriaAmerican SamoaAndorraAngolaAnguillaAntarcticaAntigua and BarbudaArgentinaArmeniaArubaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBoliviaBonaire, Sint Eustatius and SabaBosnia and HerzegovinaBotswanaBouvet IslandBrazilBritish Indian Ocean TerritoryBrunei DarussalamBulgariaBurkina FasoBurundiCambodiaCameroonCanadaCape VerdeCayman IslandsCentral African RepublicChadChileChinaChristmas IslandCocos IslandsColombiaComorosCongo, Democratic Republic of theCongo, Republic of theCook IslandsCosta RicaCroatiaCubaCuraçaoCyprusCzech RepublicCôte d'IvoireDenmarkDjiboutiDominicaDominican RepublicEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEswatini (Swaziland)EthiopiaFalkland IslandsFaroe IslandsFijiFinlandFranceFrench GuianaFrench PolynesiaFrench Southern TerritoriesGabonGambiaGeorgiaGermanyGhanaGibraltarGreeceGreenlandGrenadaGuadeloupeGuamGuatemalaGuernseyGuineaGuinea-BissauGuyanaHaitiHeard and McDonald IslandsHoly SeeHondurasHong KongHungaryIcelandIndiaIndonesiaIranIraqIrelandIsle of ManIsraelItalyJamaicaJapanJerseyJordanKazakhstanKenyaKiribatiKuwaitKyrgyzstanLao People's Democratic RepublicLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacauMacedoniaMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMartiniqueMauritaniaMauritiusMayotteMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMontserratMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew CaledoniaNew ZealandNicaraguaNigerNigeriaNiueNorfolk IslandNorth KoreaNorthern Mariana IslandsNorwayOmanPakistanPalauPalestine, State ofPanamaPapua New GuineaParaguayPeruPhilippinesPitcairnPolandPortugalPuerto RicoQatarRomaniaRussiaRwandaRéunionSaint BarthélemySaint HelenaSaint Kitts and NevisSaint LuciaSaint MartinSaint Pierre and MiquelonSaint Vincent and the GrenadinesSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSint MaartenSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSouth GeorgiaSouth KoreaSouth SudanSpainSri LankaSudanSurinameSvalbard and Jan Mayen IslandsSwedenSwitzerlandSyriaTaiwanTajikistanTanzaniaThailandTimor-LesteTogoTokelauTongaTrinidad and TobagoTunisiaTurkeyTurkmenistanTurks and Caicos IslandsTuvaluUS Minor Outlying IslandsUgandaUkraineUnited Arab EmiratesUnited KingdomUnited StatesUruguayUzbekistanVanuatuVenezuelaVietnamVirgin Islands, BritishVirgin Islands, U.S.Wallis and FutunaWestern SaharaYemenZambiaZimbabweÅland Islands Country Credit Card* American ExpressDiscoverMasterCardVisa Card Number Month010203040506070809101112 Year20212022202320242025202620272028202920302031203220332034203520362037203820392040 Expiration Date Security Code Cardholder Name Total $0.00
