Consumer PediaCard™ Registration Form

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. All fields with * are required.

I received my PediaCard™ * at an event from a Distributor from a Merchant from Charity/School my Employer
My PediaCard™ Number: (16-digit number on card) *

This is the 16 digit number on the front of your PediaCard™
Expiration Date: (on front of card) *

This is the "Good Thru" date (00/00) on the front of your card.
School/Charity Listed on Card (if any):

Name of School or Charity listed on your PediaCard™
First Name *
Last Name *
Street *
City *
State *
Zip Code *
Primary Phone * - (###) - ### ####
Secondary Phone - (###) - ### ####
Date of Birth (Optional) / MM / DD YYYY
Email *
Please select a SECRET 4-digit PIN number:
YES, Include me on the PediaCard™ e-maliing list for future announcements and discounts.
Comments or discounts you would like added to PediaCard™
Type the letters you see in the image below.