Canaspire registration - Developing a Canavan Treatment

Initial Pre-screening for the CANaspire Gene Therapy Trial

This is a secure site, and all information will be stored and processed in a confidential way, in accordance with the Health Insurance Portability and Accountability Act of 1996, commonly known as HIPAA, the Australia Privacy Act of 1988, and the Aspa Therapeutics Privacy Policy. We will ask for your consent before sharing any personal information with the clinical trial sponsor (Aspa) and its screening partners. By clicking “Submit”, you are giving permission to store the personal data you have provided. You can withdraw your interest in this research opportunity at any time by emailing us at canaspire@treatcanavan.com

About your child

Child diagnosed with Canavan disease?

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Child's gender

Baby boy Baby girl Custom

About you

Do you speak english?

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By clicking the box that says "I Agree" below, you are consenting to the use of your personal information in accordance with the terms of that Privacy Policy.

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Please note:

After submitting, a member of the Aspa team will contact you to follow-up.

By completing this form, you are not obligated to participate in the pre-screening or CANaspire Trial. You may opt out at any time.

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About your child

Child diagnosed with Canavan disease?

Yes No Not sure

Child gender

Male Female Custom

About you

Do you speak english?

Yes No

You understand that, if you complete this form and click the “SUBMIT” button, your personal information will be sent to and stored in a database in the United States and used in accordance with Aspa Therapeutics, Inc.’s Privacy Policy (“Privacy Policy”). Please review the Privacy Policy carefully. By clicking the box that says “I AGREE” below, you are (1) consenting to the use of your personal information in accordance with the terms of that Privacy Policy, and (2) if you are located in the European Union, expressly agreeing to the transfer of your Personal Data (as that term is defined in the General Data Protection Regulation, or GDPR) outside the European Union and to the United States. You may at any time request to be removed from this list by emailing your request to unsubscribe@AspaTx.com, or may exercise any of your Data Subject Access Request rights stated in the Privacy Policy by emailing your request to webadmin@AspaTx.com.

The form was sent successfully.

An error occured.

Initial Pre-screening for the CANaspire Gene Therapy Trial

About your child

About you

By clicking the box that says "I Agree" below, you are consenting to the use of your personal information in accordance with the terms of that Privacy Policy.

Please note:

After submitting, a member of the Aspa team will contact you to follow-up.

By completing this form, you are not obligated to participate in the pre-screening or CANaspire Trial. You may opt out at any time.

About your child

About you

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Initial Pre-screening for the CANaspire Gene Therapy Trial

About your child

About you

By clicking the box that says "I Agree" below, you are consenting to the use of your personal information in accordance with the terms of that Privacy Policy.

Please note: After submitting, a member of the Aspa team will contact you to follow-up. By completing this form, you are not obligated to participate in the pre-screening or CANaspire Trial. You may opt out at any time.

About your child

About you

FOLLOW US

Designed by

Please note:

After submitting, a member of the Aspa team will contact you to follow-up.

By completing this form, you are not obligated to participate in the pre-screening or CANaspire Trial. You may opt out at any time.