Before you can use your PediaCard^™ you must activate it by filling out the form below completely. All partially completed forms will be discarded. All information provided will be confidential and never released to any third parties in any form whatsoever, without your consent.

Cardholder Information:

I received my PediaCard^™:
            At an Event    From Distrbutor    Merchant     Charity/School     My Employer

My PediaCard™ Number: (16-digit number on front of card)
Card Expiration Date:
School or Charity Listed on Card (if any): (OPTIONAL)

First Name: Last Name:
Street:
City:    
State:    Zip:
Home Phone: 
Day Phone:     (OPT)
Cell Phone:     (OPT)
Date of Birth (mm/dd/yy): (OPT)
E-Mail:
E-Mail address is required for processing.
Please use your email address from your ISP. All information is strictly confidential and NEVER shared with any third parties without your permission.

Please select a SECRET 4 digit PIN number:
You must use this PIN number along with your 16 digit card number for identificatin purposes.

May we include you in our E-Mailing list for future PediaCard™ announcements and discounts?

Please list the type of promotions and discounts you would like added to the PediaCard™:

NOTICE: Please double check all of your information BEFORE you submit the form. Your email address and phone number must be correct.