(a) 2024 Academic Year Ritsumeikan Asia Pacific University Support Application

Applicant’s Name

Sex
M/FEmailAddress
PostalAddress

Senior High School Attended
Year/Month of(Expected) Graduation

School Name@〒－Home
Telephone

Cellphone*If you are applying under two or more different admission methods, complete rows 2-3 below as required. You may
make an additional copy of this form if you run out of rows.
College1

College ofCollege
2

Venue

College ofCollege
3

Venue

College of

Category
A. VisualImpairment

Venue

DateMethod

Month:
Day:□Admissions by Activity Evaluation (April/September)□Admissions for Returnee Students (April/September)□Admissions for International Baccalaureate (IB) Diploma Students(April/September)

Date

MethodMonth:
Day:□Admissions by Activity Evaluation (April/September)□Admissions for Returnee Students (April/September)□Admissions for International Baccalaureate (IB) Diploma Students(April/September)

Date

MethodMonth:
Day:□Admissions by Activity Evaluation (April/September)□Admissions for Returnee Students (April/September)□Admissions for International Baccalaureate (IB) Diploma Students(April/September)(1) Type of Disability
Circle the applicablenumbers (may be morethan one)
1. Currently receiving
education in Braille
2. Partial sight (sight instrong eye withcorrective lenses is0.15 or less)
3. 90% or greater loss ofsight in both eyes
4. Other visual
impairment(2) Special Accommodations Requested for Examinations/Interviews
Circle the applicable numbers (may be more than one)
*Ensure that the reason for each of the accommodations requested
is stated clearly in your medical certificate
1. Braille question sheets
2. Braille answer sheets
3. Large font question sheets (14 pt)
4. Large font answer sheets (14 pt)
5. Large font question sheets (22 pt)
6. Large font answer sheets (22 pt)
7. Extension of exam time (1.3 times usual)
8. Extension of exam time (1.5 times usual) (Braille only)
9. Other (please specify)

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B.
Hearing 1. Hearing ability forImpairment
both ears (average) is
60 decibels or higher
2. Other hearing
impairment

1. Use of hearing aids or bionic ear

C.
Movement/
Nervous System
Impairment

1. Unable (or difficult) tosit due to impairmentof trunk function
2. Unable (or difficult) towrite due toimpairment of upper
body function
3. Unable (or difficult) towalk due toimpairment of lower
body function
4. Other impairment ofmovement/nervoussystem
1. Autism
2. Asperger Syndrome
3. Pervasive
developmental
disorder4. Learning disability
5. Attentiondeficit/hyperactivity
disorder1. Large font answer sheets (14 pt)
2. Large font answer sheets (22 pt)
3. Extension of exam time (1.3 times usual)
4. Other (please specify)

Please specify

1. Other (please specify)

D. Developmental
Disability

E.
Other Health
Condition* If the hearing aid or bionic ear is fitted with functionality toreceive FM radio signals or the like, the device must be used withthe function switched off.
2. Use of additional paper for communication
3. Other (please specify)

1. Large font question sheets (14 pt)
2. Large font answer sheets (14 pt)
3. Large font question sheets (22 pt)
4. Large font answer sheets (22 pt)
5. Extension of exam time (1.3 times usual)
6. Use of additional paper for communication
7. Other (please specify)

Special accommodations received to date athigh school, etc.

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