In order to activate your PediaCard™ please fill 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 Member    Via Mail

My PediaCard™ Membership Number: (16-digit number on front of card)

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. NO FREE EMAIL ADDRESSES ALLOWED (hotmail, yahoo, etc)
Please use your email address from your ISP. All information is strictly confidential and NEVER shared with any third parties without your permission.

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.