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	Teen Program with Rabbi Shtick - Uptown Chabad Lubavitch
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  HIGH HOLIDAYS</a></div>
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At Uptown Chabad</div>
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<h5>Holiday Date</h5>    
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September 11 - 21, 2026</div></div>
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<form class="userform-form" action="" method="post" name="form_5605405" id="5605405" accept-charset="utf-8"><input type="hidden" name="formID" value="5605405" /><div class="form-all dir_ltr" dir="ltr"><ul class="form-section"><li class="form-line" id="id_4"><div class="form-label-left" id="label_4"><label for="input_4"> Last Name<span class="form-required">*</span> </label><label class="label-message" for="input_4"> </label></div><div id="cid_4" class="form-input"> <input type="text" class=" form-textbox validate[required]" data-type="input-textbox" id="input_4" name="q4_input4" size="20" value="" /> </div></li><li class="form-line" id="id_5"><div class="form-label-left" id="label_5"><label for="input_5"> First Name of Teen<span class="form-required">*</span> </label><label class="label-message" for="input_5"> </label></div><div id="cid_5" class="form-input"> <input type="text" class=" form-textbox validate[required]" data-type="input-textbox" id="input_5" name="q5_input5" size="20" value="" /> </div></li><li class="form-line" id="id_17"><div class="form-label-left" id="label_17"><label for="input_17"> Phone Number<span class="form-required">*</span> </label><label class="label-message" for="input_17"> </label></div><div id="cid_17" class="form-input"> <div class="dir_ltr"><span class="form-sub-label-container"><input class="form-textbox validate[required, Numeric]" type="tel" name="q17_phoneNumber[area]" id="input_17_area" autocomplete="tel-area-code" maxlength="5" size="3" />  <label class="form-sub-label" for="input_17_area" id="sublabel_area">Area Code</label></span><span class="form-sub-label-container"><input class="form-textbox validate[required, Numeric]" type="tel" name="q17_phoneNumber[phone]" id="input_17_phone" autocomplete="tel-local" size="8" />  <label class="form-sub-label" for="input_17_phone" id="sublabel_phone">Phone Number</label></span></div> </div></li><li class="form-line" id="id_18"><div class="form-label-left" id="label_18"><label for="input_18"> E-mail<span class="form-required">*</span> </label><label class="label-message" for="input_18"> </label></div><div id="cid_18" class="form-input"> <input type="email" class=" form-textbox validate[required, Email]" id="input_18" name="q18_email" size="30" value="" autocomplete="email" /> </div></li><li class="form-line" id="id_28"><div class="form-label-left" id="label_28"><label for="input_28"> Name of Teen<span class="form-required">*</span> </label><label class="label-message" for="input_28"> </label></div><div id="cid_28" class="form-input"> <input type="text" class=" form-textbox validate[required]" data-type="input-textbox" id="input_28" name="q28_input28" size="20" value="" /> </div></li><li class="form-line" id="id_8"><div class="form-label-left" id="label_8"><label for="input_8"> Birth Date of Teen<span class="form-required">*</span> </label><label class="label-message" for="input_8"> </label></div><div id="cid_8" class="form-input"> <div class="dir_ltr"><span class="form-sub-label-container"><select class="form-dropdown validate[required]" name="q8_birthDate[month]" id="input_8_month"><option></option><option value="1">1 - January</option><option value="2">2 - February</option><option value="3">3 - March</option><option value="4">4 - April</option><option value="5">5 - May</option><option value="6">6 - June</option><option value="7">7 - July</option><option value="8">8 - August</option><option value="9">9 - September</option><option value="10">10 - October</option><option value="11">11 - November</option><option value="12">12 - December</option></select>  <label class="form-sub-label" for="input_8_month" id="sublabel_month">Month</label></span><span class="form-sub-label-container"><select class="form-dropdown validate[required]" name="q8_birthDate[day]" id="input_8_day"><option></option><option value="1">1</option><option value="2">2</option><option value="3">3</option><option value="4">4</option><option value="5">5</option><option value="6">6</option><option value="7">7</option><option value="8">8</option><option value="9">9</option><option value="10">10</option><option value="11">11</option><option value="12">12</option><option value="13">13</option><option value="14">14</option><option value="15">15</option><option value="16">16</option><option value="17">17</option><option value="18">18</option><option value="19">19</option><option value="20">20</option><option value="21">21</option><option value="22">22</option><option value="23">23</option><option value="24">24</option><option value="25">25</option><option value="26">26</option><option value="27">27</option><option value="28">28</option><option value="29">29</option><option value="30">30</option><option value="31">31</option></select>  <label class="form-sub-label" for="input_8_day" id="sublabel_day">Day</label></span><span class="form-sub-label-container"><select class="form-dropdown validate[required]" name="q8_birthDate[year]" id="input_8_year"><option></option><option value="2025">2025</option><option value="2024">2024</option><option value="2023">2023</option><option value="2022">2022</option><option value="2021">2021</option><option value="2020">2020</option><option value="2019">2019</option><option value="2018">2018</option><option value="2017">2017</option><option value="2016">2016</option><option value="2015">2015</option><option value="2014">2014</option><option value="2013">2013</option><option value="2012">2012</option><option value="2011">2011</option><option value="2010">2010</option><option value="2009">2009</option><option value="2008">2008</option><option value="2007">2007</option><option value="2006">2006</option><option value="2005">2005</option><option value="2004">2004</option><option value="2003">2003</option><option value="2002">2002</option><option value="2001">2001</option><option value="2000">2000</option><option value="1999">1999</option><option value="1998">1998</option><option value="1997">1997</option><option value="1996">1996</option><option value="1995">1995</option><option value="1994">1994</option><option value="1993">1993</option><option value="1992">1992</option><option value="1991">1991</option><option value="1990">1990</option><option value="1989">1989</option><option value="1988">1988</option><option value="1987">1987</option><option value="1986">1986</option><option value="1985">1985</option><option value="1984">1984</option><option value="1983">1983</option><option value="1982">1982</option><option value="1981">1981</option><option value="1980">1980</option><option value="1979">1979</option><option value="1978">1978</option><option value="1977">1977</option><option value="1976">1976</option><option value="1975">1975</option><option value="1974">1974</option><option value="1973">1973</option><option value="1972">1972</option><option value="1971">1971</option><option value="1970">1970</option><option value="1969">1969</option><option value="1968">1968</option><option value="1967">1967</option><option value="1966">1966</option><option value="1965">1965</option><option value="1964">1964</option><option value="1963">1963</option><option value="1962">1962</option><option value="1961">1961</option><option value="1960">1960</option><option value="1959">1959</option><option value="1958">1958</option><option value="1957">1957</option><option value="1956">1956</option><option value="1955">1955</option><option value="1954">1954</option><option value="1953">1953</option><option value="1952">1952</option><option value="1951">1951</option><option value="1950">1950</option><option value="1949">1949</option><option value="1948">1948</option><option value="1947">1947</option><option value="1946">1946</option><option value="1945">1945</option><option value="1944">1944</option><option value="1943">1943</option><option value="1942">1942</option><option value="1941">1941</option><option value="1940">1940</option><option value="1939">1939</option><option value="1938">1938</option><option value="1937">1937</option><option value="1936">1936</option><option value="1935">1935</option><option value="1934">1934</option><option value="1933">1933</option><option value="1932">1932</option><option value="1931">1931</option><option value="1930">1930</option><option value="1929">1929</option><option value="1928">1928</option><option value="1927">1927</option><option value="1926">1926</option><option value="1925">1925</option><option value="1924">1924</option><option value="1923">1923</option><option value="1922">1922</option><option value="1921">1921</option><option value="1920">1920</option></select>  <label class="form-sub-label" for="input_8_year" id="sublabel_year">Year</label></span></div> </div></li><li class="form-line" id="id_20"><div class="form-label-left" id="label_20"><label for="input_20"> Gender<span class="form-required">*</span> </label><label class="label-message" for="input_20"> </label></div><div id="cid_20" class="form-input"> <div class="form-single-column"><span class="form-radio-item clear-left"><input type="radio" class="form-radio validate[required]" id="input_20_0" name="q20_input20" value="Male" /><label id="label_input_20_0" for="input_20_0"><span>Male</span></label></span><span class="clearfix"></span><span class="form-radio-item clear-left"><input type="radio" class="form-radio validate[required]" id="input_20_1" name="q20_input20" value="Female" /><label id="label_input_20_1" for="input_20_1"><span>Female</span></label></span><span class="clearfix"></span></div> </div></li><li class="form-line" id="id_37"><div class="form-label-left" id="label_37"><label for="input_37"> I will attend: </label><label class="label-message" for="input_37"> </label></div><div id="cid_37" class="form-input"> <div class="form-single-column"><span class="form-checkbox-item clear-left"><input type="checkbox" class="form-checkbox" id="input_37_0" name="q37_input37[]" value="High Holiday prep and pizza meeting September 18, 6:30pm (1.5 hours of volunteering)" /><label id="label_input_37_0" for="input_37_0"><span>High Holiday prep and pizza meeting September 18, 6:30pm (1.5 hours of volunteering)</span></label></span><span class="clearfix"></span><span class="form-checkbox-item clear-left"><input type="checkbox" class="form-checkbox" id="input_37_1" name="q37_input37[]" value="Rosh Hashanah Day 1 September 23, 10:30 am- 1:00 pm (2.5 hours of volunteering)" /><label id="label_input_37_1" for="input_37_1"><span>Rosh Hashanah Day 1 September 23, 10:30 am- 1:00 pm (2.5 hours of volunteering)</span></label></span><span class="clearfix"></span><span class="form-checkbox-item clear-left"><input type="checkbox" class="form-checkbox" id="input_37_2" name="q37_input37[]" value="Rosh Hashanah Day 2 September 24, 10:30 am- 1:00 pm (2.5 hours of volunteering)" /><label id="label_input_37_2" for="input_37_2"><span>Rosh Hashanah Day 2 September 24, 10:30 am- 1:00 pm (2.5 hours of volunteering)</span></label></span><span class="clearfix"></span><span class="form-checkbox-item clear-left"><input type="checkbox" class="form-checkbox" id="input_37_3" name="q37_input37[]" value="Yom Kippur October 2, 10:30 am - 1:00 pm (2.5 hours of volunteering)" /><label id="label_input_37_3" for="input_37_3"><span>Yom Kippur October 2, 10:30 am - 1:00 pm (2.5 hours of volunteering)</span></label></span><span class="clearfix"></span></div> </div></li><li class="form-line" id="id_2"><div id="cid_2" class="form-input-wide"> <div style="text-align: center; text-indent:156px;" class="form-buttons-wrapper button-align-auto"><button id="input_2" type="submit" class="form-submit-button  form-submit-button-none;">Submit</button></div> </div></li><li class="form-line" id="id_14"><div id="cid_14" class="form-input-wide"> <div id="text_14" class="form-html"><p><em><span style="color: rgb(0, 51, 0);">* No synagogue membership</span><span style="color: rgb(0, 51, 0);"> or seat fees are necessary as a prerequisite to participating in High Holidays with Rabbi Shtick. This program is included for those who do purchase <a href="http://uptownchabad.com/3025936">membership</a> or <a href="/Article.asp?AID=3030946">seats</a>.</span></em></p></div> </div></li><li style="display:none">Should be Empty: <input type="text" name="website" value="" /></li></ul></div><input type="hidden" id="simple_spc" name="simple_spc" value="5605405" /><script type="text/javascript">document.getElementById("si"+"mple"+"_spc").value = "5605405-5605405";</script></form></div>
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