Form 1

Application for Reasonable Accommodation

This form is for students with disabilities who wish to request reasonable accommodation to facilitate their studies at Kyoto University. Please complete the form and submit
it to your faculty/department of affiliation together with documents verifying the details of your disability, such as a medical certificate, examination results, or a disabilitycertificate. Please note that reasonable accommodation is provided in accordance with the Kyoto University Guidelines which are based on the Japanese government's Act forEliminating Discrimination against Persons with Disabilities.
Date:

To the Dean of Faculty/Graduate School of, Kyoto University

Name in Hiragana

Faculty/Graduate School

Division/Department

Student ID Number

NameYear of Enrollment

Date of BirthGender〒
Current Address

E-mailEmergency Contact
Person(Parent, guardian,guarantor etc.)
Details of yourdisability

PC:
Mobile:Mobile:Address: 〒Phone:Name:
Visual/(Relationship to the student:

Hearing/

Physical/

Health/Developmental)/

Mental/Other

Name of the disability (or illness) that you have been diagnosed with:

Do you use any
assistive devices?
Do you have a medical
certificate?*1Yes / No

Do you have a disability
certificate?*3

Yes / No

External organization thatyou currently attend fortreatment or support(Hospital, supportorganization, etc.)

Home:

Telephone Number

Do you have other materials which indicate examination
results regarding your disability or the degree of yourdisability?*2
Physical/Mental/Rehabilitation

Name of organization:/

Yes /No

Other （*Please submit either *1, *2, or *3
together with this form.

Grade）

TypePhone:

Person in charge:

Details of the issues
which will cause
difficulties in yourstudiesDetails of the support /reasonableaccommodation
required*Please note: The purpose of this form is to confirm your needs and the degree of disability at the time of application. The details of any reasonable accommodation to beprovided will not be based only on this application.

Attached documents□ Copy of your student ID card
□ Materials which indicate the details of your disability（□ Medical certificate □ Copy of your disability certificate□ Other:）◆ Handling of Personal Information□ Personal information provided in this application form will be shared with the Disability Resource Center (DRC) in order to facilitate the applicant's study at Kyoto University. If it is necessary toshare the applicant's personal information with faculties/departments other than the DRC in order to provide the requested reasonable accommodation, the extent to which the information will beshared shall be determined in consultation between the applicant and the relevant staff member(s) in the applicant's faculty/department of affiliation.
□ Kyoto University may provide external organizations or groups with statistical information about the number of students with disabilities at the university and their faculties of affiliation/academic
grades/types of disabilities. However, the university will not provide names or any other personally identifiable information to such parties.

◆ Points to Note

□ The relevant staff member(s) in the educational affairs section of the applicant's faculty/department of affiliation will meet with the applicant once a year to confirm the contents of the applicationwith them.
□ The applicant is forbidden to use any information acquired through the reasonable accommodation or support provided for any purposes other than pursuing their studies at Kyoto University.

I confirm that I have read, understood, and agree to the items above, and I hereby apply for reasonable accommodation.
Applicant's signature:

支援責任者（教員）

Office Use Only 学部・研究科等 記入欄
支援担当者（職員）年（内線：Disability Resource Center Use Only
申請書（写）受取日
担当者

申請書受理日）月日

年月日