szurubooru/public_html/templates/account-removal.tpl

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<div class="messages"></div>
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<form class="form-wrapper account-removal">
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<div class="form-row">
<label class="form-label" for="account-removal-confirmation">Confirmation:</label>
<div class="form-input">
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<input type="checkbox" id="account-removal-confirmation" name="confirmation"/>
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<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>
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</div>
</div>
</form>