szurubooru/public_html/templates/account-removal.tpl

<div class="messages"></div>

<form class="form-wrapper account-removal">
    <div class="form-row">
        <label class="form-label" for="account-removal-confirmation">Confirmation:</label>
        <div class="form-input">
            <input type="checkbox" id="account-removal-confirmation" name="confirmation"/>
            <label for="account-removal-confirmation">
                I confirm that I want to delete this account.
            </label>
        </div>
    </div>

    <div class="form-row">
        <label class="form-label"></label>
        <div class="form-input">
            <button type="submit">Delete account</button>
        </div>
    </div>
</form>