| No | Nama Peserta | Cabor | Asal | No. Pelatih Lv 1 | No. Pelatih Lv 2 |
| 1 | DWI ANGGORO SAPUTRO, S.Pd. | Sepak Bola | PERSITEMA | 182002702 | L2002702 |
| 2 | FITRIYADI | Panjat Tebing | KALIMANTAN TIMUR | 192004104 | L2004104 |
| 3 | GALLANT PAMUNGKAS | Balap Sepeda | JAWA TENGAH | 202005275 | L2005275 |
| 4 | IR.PURWANTO IMAN SANTOSO | Sepak Bola | JAWA BARAT | 202004555 | L2004555 |
| 5 | JAMAL IMAM ARIYADI, S.Pd. | Anggar | JAWA TENGAH | 192003738 | L2003738 |
| 6 | KEVIN RAMADHAN | Renang | JAWA BARAT | 182003111 | L2003111 |
| 7 | LUKMANUL HAKIM, S.Pd. | | JAWA TENGAH | 182002724 | L2002724 |
| 8 | MUHAMMAD AMIN | Sepak Bola | KALIMANTAN TIMUR | 192004355 | L2004355 |
| 9 | NAFISA ARIF PAMBUDI | Rugby | YOGYAKARTA | 192004360 | L2004360 |
| 10 | SULAIMAN DWI PUTRA NUGROHO | Gymastics | DKI JAKARTA | 192004374 | L2004374 |
| 11 | TITIS PAMBUDI, S.Pd. | Badminton | JAWA TENGAH | 192004134 | L2004134 |
