2. Family Name*
4. Primary Contact Name*
6. Primary Contact Phone*
7. Primary Contact Email*
9. Family Story / Narrative (500 character limit)*

   Please note: Based on the total number of family submissions received, the maximum character count may be adjusted as needed at the discretion of the Bicentennial Book volunteers to ensure proper formatting and inclusion of all entries.

11. Photo Upload (Limit 1 per entry)*
13. Photo Caption / Description
15. Permission*

    1. I grant permission for my family’s story / photo to be printed in the Bicentennial Book and related displays.
17. Acknowledgement*

    1. I acknowledge, placement, text and inclusion are subject to editorial review.
19. Payment Coordination

    Following receipt of your submission, the Village of Doylestown Fiscal Office will contact you to coordinate payment of the $20 submission fee for inclusion of your family story and photo in the Bicentennial Book. Payment may be made by cash, check, or credit card.

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21. 1. Receive an email copy of this form.
22. Email address

    This field is not part of the form submission.

23. Submit

* indicates a required field