New Candidate Form for the CANaspire Gene Therapy Trial

For Parents or Guardians
For Health Care Providers

1ELIGIBILITY

2YOUR INFORMATION

If you are a parent/guardian who wishes to express interest in the trial, please complete the form below. The Communication Coordinator, a third-party independent contractor, will respond to your email as soon as possible and within 3 business days.

Please note the following information:

The sponsor, Aspa Therapeutics, will not have access to your or your child’s personal or medical information. The Communication Coordinator is not a direct employee of Aspa Therapeutics.
The study doctors will be responsible for determining if your child meets the requirements for participation in the clinical trial.
Submission of this form does not guarantee your child’s participation or obligate you to enroll your child in the CANaspire gene therapy trial.

About your child

What is your child's first or given name? * *

Has your child been diagnosed with Canavan disease?

Yes
No
I'm not sure

What is your child’s gender?

Male / Boy
Female / Girl

Please provide your child's date of birth *

Please provide your child's date of birth

Day *

Month *

Year *

About you

What is your name? * *

What is your relationship to the child?

What country do you live in currently?

What is your preferred spoken language?

What is your email address? * *

Confirm Email

What is your phone number including country and area code? * *

Before submitting this form, you are required to agree to the following terms. If you do not fully understand these terms or have questions, please send an email to CANaspire@aspatx.com.

All information will be stored and processed in a confidential way, in accordance with Aspa Therapeutics’ parent company’s (BridgeBio) Privacy Policy.
All information will be shared with the CANaspire study doctors for the sole purpose of determining whether your child can be considered for screening.

By clicking the box that says "I Agree" below, you are consenting to the use of your personal information in accordance with the terms outlined above. If you do not click the “I Agree” box, no information will be sent to the Communication Coordinator and you will not receive further contact regarding the clinical trial.

* Mandatory fields

Term Agreement *

I Agree

If you are a healthcare provider and would like to refer a child under your care, please send an email to CANaspire@aspatx.com. Please do not include personal identifying information such as name, date of birth, or address (this will be deleted). The Communication Coordinator, a third-party independent contractor, will respond to your email as soon as possible but within 3 business days.

New Candidate Form for the CANaspire Gene Therapy Trial

About your child

About you

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