Butterfly Dreamz Book Request

1
Which book are you requesting? * This field is required.
The Leadership Journal Vol. 1 (women and girls)
Book Club Selection (May 3rd deadline)
2
Click the book image to browse or purchase an electronic copy of The Leadership Journal. Click the "Next" button to continue requesting a hard copy.
3
Which best describes you?* This field is required.
Middle School Girl
High School Girl
Mentor to girl(s)
Program Leader
Parent/Guardian of girl(s)
4
How many books would you like to purchase?* This field is required.Your book(s) will arrive in 7-10 business days. We'll pay for shipping and send you the tracking info!
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My Bag
1
My Bag
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$20
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Great Product Name
$20
Quantity:1
Size:Small
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Great Product Name
$20
Quantity:1
Size:Small
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Great Product Name
$20
Quantity:1
Size:Small
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ORDER SUMMARY
Total costUSD
The Leadership Journal: Let's Talk
$20.00+
Back
Quantity
Subtotal: $0.00
Total cost $0.00
5
What's your name?* This field is required.
First Name
Last Name
6
What's your email address?* This field is required.
example@example.com
7
Phone Number* This field is required.
Area Code
Phone Number
8
Are you a member of our Cocoon Club? * This field is required.
YESNO
9
Thank you for your interest in our books! At this time, only Cocoon Club members can request books. To join the club, visit cocoonclub.org/join. Membership is FREE for middle & high school girls and women mentors. Hit the "submit" button at the bottom right if you'd like to leave your contact information and/or any comments or questions.
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10
Which type of book would you like?* This field is required.
An e-book (sent by email)
A hard copy (sent by snail mail)
11
Where should we send your book(s)?* This field is required.
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Please Select
Please Select
United States
Afghanistan
Albania
Algeria
American Samoa
Andorra
Angola
Anguilla
Antigua and Barbuda
Argentina
Armenia
Aruba
Australia
Austria
Azerbaijan
The Bahamas
Bahrain
Bangladesh
Barbados
Belarus
Belgium
Belize
Benin
Bermuda
Bhutan
Bolivia
Bosnia and Herzegovina
Botswana
Brazil
Brunei
Bulgaria
Burkina Faso
Burundi
Cambodia
Cameroon
Canada
Cape Verde
Cayman Islands
Central African Republic
Chad
Chile
China
Christmas Island
Cocos (Keeling) Islands
Colombia
Comoros
Congo
Cook Islands
Costa Rica
Cote d'Ivoire
Croatia
Cuba
Curacao
Cyprus
Czech Republic
Democratic Republic of the Congo
Denmark
Djibouti
Dominica
Dominican Republic
Ecuador
Egypt
El Salvador
Equatorial Guinea
Eritrea
Estonia
Ethiopia
Falkland Islands
Faroe Islands
Fiji
Finland
France
French Polynesia
Gabon
The Gambia
Georgia
Germany
Ghana
Gibraltar
Greece
Greenland
Grenada
Guadeloupe
Guam
Guatemala
Guernsey
Guinea
Guinea-Bissau
Guyana
Haiti
Honduras
Hong Kong
Hungary
Iceland
India
Indonesia
Iran
Iraq
Ireland
Israel
Italy
Jamaica
Japan
Jersey
Jordan
Kazakhstan
Kenya
Kiribati
North Korea
South Korea
Kosovo
Kuwait
Kyrgyzstan
Laos
Latvia
Lebanon
Lesotho
Liberia
Libya
Liechtenstein
Lithuania
Luxembourg
Macau
Macedonia
Madagascar
Malawi
Malaysia
Maldives
Mali
Malta
Marshall Islands
Martinique
Mauritania
Mauritius
Mayotte
Mexico
Micronesia
Moldova
Monaco
Mongolia
Montenegro
Montserrat
Morocco
Mozambique
Myanmar
Nagorno-Karabakh
Namibia
Nauru
Nepal
Netherlands
Netherlands Antilles
New Caledonia
New Zealand
Nicaragua
Niger
Nigeria
Niue
Norfolk Island
Turkish Republic of Northern Cyprus
Northern Mariana
Norway
Oman
Pakistan
Palau
Palestine
Panama
Papua New Guinea
Paraguay
Peru
Philippines
Pitcairn Islands
Poland
Portugal
Puerto Rico
Qatar
Republic of the Congo
Romania
Russia
Rwanda
Saint Barthelemy
Saint Helena
Saint Kitts and Nevis
Saint Lucia
Saint Martin
Saint Pierre and Miquelon
Saint Vincent and the Grenadines
Samoa
San Marino
Sao Tome and Principe
Saudi Arabia
Senegal
Serbia
Seychelles
Sierra Leone
Singapore
Slovakia
Slovenia
Solomon Islands
Somalia
Somaliland
South Africa
South Ossetia
South Sudan
Spain
Sri Lanka
Sudan
Suriname
Svalbard
eSwatini
Sweden
Switzerland
Syria
Taiwan
Tajikistan
Tanzania
Thailand
Timor-Leste
Togo
Tokelau
Tonga
Transnistria Pridnestrovie
Trinidad and Tobago
Tristan da Cunha
Tunisia
Turkey
Turkmenistan
Turks and Caicos Islands
Tuvalu
Uganda
Ukraine
United Arab Emirates
United Kingdom
Uruguay
Uzbekistan
Vanuatu
Vatican City
Venezuela
Vietnam
British Virgin Islands
Isle of Man
US Virgin Islands
Wallis and Futuna
Western Sahara
Yemen
Zambia
Zimbabwe
Other
Country
12
How many free books are you requesting?* This field is required.
0
1
2
13
Invoice ID
14
Please type the email address where you would like us to send your e-book:* This field is required.
example@example.com
15
Parent/Guardian Signature* This field is required.By signing below, I give consent for my child to read and receive a copy of the selected book(s).
Clear
16
Parent/Guardian Name* This field is required.
First Name
Last Name
17
Parent/Guardian Phone Number* This field is required.
Area Code
Phone Number
18
Parent/Guardian Email* This field is required.
example@example.com
Should be Empty: